Cotiviti
Cotiviti
Cotiviti is a healthcare technology and analytics company that helps health plans, government agencies, and healthcare providers improve payment accuracy, operational performance, and care quality. Its data-driven solutions support risk adjustment, payment policy management, and member engagement, turning complex healthcare information into insights that can strengthen both financial and clinical outcomes across the healthcare ecosystem.

DRG Validation Auditor – CMS Audits (Remote, United States)

Audit inpatient DRG claims for Cotiviti by reviewing medical records, validating coding, and identifying billing issues. Document recovery findings and support accurate CMS audit determinations.

Description

  • Audit inpatient DRG claims using coding principles and client-specific audit guidelines
  • Independently review and interpret medical records
  • Apply advanced coding expertise to identify potential billing and coding issues
  • Use clinical and industry knowledge to support audit conclusions
  • Operate Cotiviti’s proprietary systems to determine audit outcomes and produce audit letters
  • Achieve productivity targets set by audit operations leadership
  • Maintain required accuracy and quality standards for claim identification and documentation
  • Spot additional recovery opportunities beyond the assigned audit concept
  • Recommend and develop valuable audit concepts, process improvements, and tools
  • Fulfill responsibilities outlined in the annual performance plan
  • Complete special projects and other assigned duties

Requirements

  • Associate or bachelor’s degree in Health Information Management, with RHIA or RHIT credentials
  • High school diploma or GED with at least five years of equivalent claims auditing, quality assurance, or recovery auditing experience may be accepted instead, preferably in DRG or clinical validation audits or a hospital setting
  • Maintain at least one of these certifications: RHIA, RHIT, CPC, CCS, CIC, CDIP, or CCDS
  • Bring 5–7 or more years of experience with ICD-9/10-CM, MS-DRG, AP-DRG, and APR-DRG
  • Understand medical claims billing and payment systems, provider billing rules, payer reimbursement policies, medical necessity criteria, and coding terminology
  • Follow official coding guidelines, Coding Clinic determinations, CMS requirements, and other applicable regulatory mandates
  • Demonstrate expert knowledge of DRG, APR-DRG, ICD-10, CPT, and HCPCS codes
  • Understand relevant industry standards
  • Use Word, Access, Excel, Teams, and other business applications proficiently
  • Communicate clearly in writing and verbally
  • Exchange information effectively with colleagues and other stakeholders
  • Evaluate assigned work for accuracy, organization, and completeness
  • Provide a dedicated and secure workspace
  • Maintain high-speed internet connectivity and an appropriate office setup
  • Perform the role’s duties with or without reasonable accommodation

Benefits

  • Eligibility for discretionary bonus consideration
  • Medical insurance
  • Dental insurance
  • Vision insurance
  • Disability insurance
  • Life insurance
  • 401(k) savings plans
  • Paid family leave
  • Nine paid holidays annually
  • 17–27 days of paid time off per year, based on level and length of service
  • Overtime pay for hours exceeding 40 in a week, or as required by applicable state law

Related Jobs