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Clinical Validation Auditor – Outpatient Specialty (Remote)
Validate outpatient and specialty claims for Cotiviti’s healthcare payment integrity services. Review clinical records, coding accuracy, medical necessity, and services delivered.
विवरण
- Audit outpatient and specialty claims, including APC, PNPP, pharmacy, and/or inpatient DRG claims
- Conduct coding and clinical chart validation for outpatient and specialty audits
- Examine medical records to identify billing and coding discrepancies
- Evaluate clinical review findings, coding accuracy, medical necessity, treatment settings, and delivered services
- Apply medical chart coding standards and client-specific guidelines
- Use Cotiviti Encoder and related audit tools
- Enter claims accurately into Cotiviti’s system
- Meet productivity, accuracy, quality, and valid claim identification and documentation standards
- Flag potential claims outside the assigned audit concept when additional recovery opportunities may exist
- Recommend and develop audit concepts, process improvements, tools, and technology enhancements
- Apply ideas and methods that support audit production, communication, and client satisfaction
- Analyze information and reach sound conclusions
- Complete annual Performance Plan responsibilities, special projects, and other assigned duties
आवश्यकताएँ
- Associate or bachelor’s degree in nursing
- Active, unrestricted nursing license
- Maintain a required coding certification such as CPC, CIC, CCS, CCS-P, RHIA, or RHIT
- Five to seven years of experience in clinical medical record coding or auditing
- Working knowledge of HIPAA Privacy and Security Rules and CMS security requirements
- Broad knowledge of medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology
- Ability to learn and become proficient in outpatient and specialty review types
- Follow official coding guidelines, Coding Clinic determinations, and CMS and other regulatory compliance requirements
- Expertise with DRG, ICD-10, CPT, and HCPCS codes
- Strong verbal and written communication skills
- Ability to work independently and collaboratively
- Ability to maintain a dedicated, secure work area
- Ability to provide high-speed internet connectivity and maintain the required office setup
- Ability to perform the role with or without reasonable accommodation
लाभ
- Eligibility for discretionary bonus consideration
- Medical insurance
- Dental insurance
- Vision insurance
- Disability insurance
- Life insurance
- 401(k) savings plan
- Paid family leave
- Nine paid holidays per year
- 17–27 days of paid time off per year, based on level and length of service
- Overtime pay for nonexempt employees working more than 40 hours per week or as required by state law
- Remote work arrangement
- Team-member-provided dedicated, secure work area and high-speed internet and office setup
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