Auditor Clinical Validation DRG

Cotiviti - South Jordan, UT

Full-time

Remote - South Jordan, UT

Professional, Scientific, and Technical Services

About the position

The Auditor Clinical Validation DRG position at Cotiviti, Inc. is a full-time role focused on auditing inpatient claims with an emphasis on clinical review, coding accuracy, and the appropriateness of treatment settings and services delivered. The ideal candidate will possess a combination of clinical nursing and coding/auditing expertise, particularly in Inpatient DRG/APR-DRG disciplines. This role requires independent work and the ability to utilize proprietary auditing systems effectively to meet productivity and quality standards.

Responsibilities

• Analyzes and audits claims, integrating medical chart coding principles and clinical guidelines.
• Utilizes Cotiviti proprietary auditing systems proficiently to make audit determinations and generate audit letters.
• Maintains production goals set by the audit operations management team.
• Achieves expected levels of accuracy and quality for valid claim identification and documentation.
• Identifies potential claims outside of the concept for additional recoveries and suggests process improvements.
• Completes all responsibilities outlined on the annual Performance Plan and special projects as assigned.

Requirements

• Associate or bachelor's degree in nursing (active/unrestricted license) or Health Information Management (RHIA or RHIT).
• Coding/CDI Certification (RHIA, RHIT, CPC, CCS, CIC, CDIP, or CCDS) is required and must be maintained.
• 5 to 7+ years of experience with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG.
• Broad knowledge of medical claims billing/payment systems, provider billing guidelines, and payer reimbursement policies.
• Expert knowledge of coding guidelines, including DRG, APR-DRG, ICD-10, CPT, and HCPCS codes.
• Proficiency in Word, Access, Excel, TEAMS, and other applications.
• Excellent written and verbal communication skills.