Job details

Auditor, Clinical Validation (Place of Service, Short Stay & Readmission)

Overview:

This auditing role will focus on Clinical Chart Validation for our Place of Service, Short Stay & Readmission audits....this position may also flex in to other audit areas as needed. The ideal candidate for this position needs to have both clinical (RN) experience and a thorough understanding of: CMS inpatient and outpatient guidelines, clinical / medical necessity, re-admission and other policies experience. This position is responsible for auditing claims and documenting the results of those audits. with a focus on clinical review, coding accuracy, medical necessity, and the appropriateness of treatment setting and services delivered.

Responsibilities:

Audits Medical Records:
- Utilizes clinical & coding principles and client specific guidelines in performance of medical audit activities with short stay & readmission reviews.
- Draws on advanced clinical expertise and industry knowledge to substantiate conclusions.
- Performs work independently, reviews and interprets medical records and applies in-depth knowledge of clinical and some coding principles to determine potential issues.
Effectively Utilizes Audit Tools
- Utilizes with advanced proficiency, Cotiviti clinical, encoder and audit tools required to perform duties.
- Enters the claim into Cotiviti system accurately and in accordance with standard procedures.
- Meets or Exceeds Standards/Guidelines for Productivity. Maintains production goals, accuracy and quality standards set by the audit for the auditing concept.
Meets or Exceeds Standards/Guidelines for Quality
- Achieves the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation.
Identifies New Claim Types
- Identifies potential claims outside of the concept where additional recoveries may be available.
- Suggests and develops high quality, high value concepts and/or processes improvement, tools, etc.
Recommends New Concepts and Processes
- Has broad in-depth knowledge of client, contract terms and complex claim types gained from extensive healthcare auditing experience.
- Suggests, develops and implements new ideas, approaches and/or technological improvements that will support and enhance audit production, communication and client satisfaction.
- Evaluates information and draws logical conclusions.

Qualifications:

Education (required)-
- Associates or Bachelor's degree in Nursing (active / unrestricted license)
Certification (preferred)
- Case Management certification - preferred
- Outpatient or Inpatient Coding Credential - CCS, CPC or CIC - preferred
Experience
- Clinical experience required (experience in ER, critical care, OR, cath lab, or GI lab preferred)
- Case Management experience highly preferred
- High level of proficiency in Milliman and Interqual guidelines (as well as an understanding of the CMS inpatient only list)
- 3-5 years of medical record auditing or similar experience preferred
- Ability to utilize and analyze clinical auditing knowledge and skills to learn and become proficient in a variety of review types such as DRG, SNF, Home Health, DME, Hospice, Re-admissions, Short Stay and therapy reviews
- Adherence to official clinical or coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines and mandates.
- Requires working knowledge of and applicable industry based standards.
- Proficiency in Word, Access, Excel and other applications.
- Excellent written and verbal communication skills.
- Ability to work well in an individual and team environment.

Work Environment:

This is an at home-based position and you must have a work location within the continental US
This position requires that you provide a high-speed internet connection and a work environment free from distractions (all other equipment will be provided by the company).
Training is done virtually and requires you work specific hours and be on camera for a good portion of the training.
This role is aligned to certain productivity and quality requirements
Must be able to sit and use a computer keyboard for extended periods of time
Must have flexibility and willingness to participate in the work processes of an international organization, including conference calls scheduled to accommodate global time zones.

Base compensation is paid hourly at $44.23/hour (92k annualized). This role is eligible for discretionary bonus consideration.

Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti. For information about our benefits package, please refer to our Careers page.

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CEO of Cotiviti

Emad Rizk, M.D.

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By Cotiviti

Cotiviti, a premier analytics and solutions firm, harnesses vast clinical and financial data to offer insights that enhance the efficiency, quality, and financial health of the healthcare system.

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