LogoFresh Jobs Ahead
Cotiviti
Cotiviti
5 001 – 10 000 Xodimlar
H1B vizasi homiysiKonsaltingLogistikaSog‘liqni saqlash
Cotiviti tibbiy sug‘urta rejalari, davlat idoralari va tibbiy xizmat ko‘rsatuvchi tashkilotlarga to‘lovlar aniqligini, operatsion samaradorlikni va tibbiy yordam sifatini yaxshilashda yordam beradigan sog‘liqni saqlash texnologiyalari va tahlil kompaniyasidir. Uning ma’lumotlarga asoslangan yechimlari xavflarni moslashtirish, to‘lov siyosatini boshqarish va a’zolar bilan aloqani qo‘llab-quvvatlab, murakkab tibbiy ma’lumotlarni foydali tahliliy xulosalarga aylantiradi. Bu sog‘liqni saqlash ekotizimining barcha bo‘g‘inlarida moliyaviy va klinik natijalarni mustahkamlashga yordam beradi.
LinkedIn
Kompaniyadagi ish o‘rinlari

Senior Appeals Auditor – Cotiviti (Remote, US)

Defend Cotiviti’s recovery decisions by reviewing Medicare claims, clinical records, coding, medical necessity, and provider appeals. Prepare evidence-based appeal responses and support cases progressing to Administrative Law Judge hearings.

USAmerika Qo‘shma Shtatlari
47 $ – 57 $ / soat
MasofaviyTo‘liq stavkaSeniorTalab Qilinadigan Til: inglizchaAuditor

Tavsif

  • Defend recovery decisions and appeals involving SNF, IRF, home health, DME, and hospice claims.
  • Review appealed outpatient and specialty claims against coding principles, client-specific rules, and appeals guidelines.
  • Examine initial claims, supporting records, and additional information submitted by providers.
  • Interpret medical records and apply coding principles, medical necessity criteria, and appeals regulations to reach determinations.
  • Draft factual, well-supported, grammatically correct responses tailored to each provider claim.
  • Use Cotiviti encoder and audit tools, and enter appeal claims accurately into company systems.
  • Meet production, accuracy, quality, productivity, and service-level expectations.
  • Give initial audit teams and QA educational feedback based on appeal outcomes.
  • Recommend and implement improvements to appeals concepts, processes, and technology.
  • Research disputes involving MAC decisions, LCDs, NCDs, and MAC-specific billing and documentation rules.
  • Compare MAC guidance with CMS manuals, regulations, and Cotiviti policy to find conflicts or gaps.
  • Organize findings, supporting records, escalations, and communications with MACs, payers, and clients.
  • Monitor MAC decisions and trends, and alert leadership to recurring issues.
  • Support cases that proceed to the Administrative Law Judge appeal stage.
  • Prepare case summaries, clinical timelines, position papers, medical-record excerpts, policy citations, and hearing exhibits.
  • Assess case strengths and weaknesses, anticipate provider arguments, and develop rebuttals.
  • Support legal, compliance, and hearing staff with research, fact-checking, and clinical or coding rationale.
  • Help prepare for hearings through pre-hearing discussions and by providing clinical and coding expertise.
  • Take on QA auditor or initial auditor duties when business needs require.
  • Complete assigned special projects and other duties.

Talablar

  • Associate’s or bachelor’s degree in nursing.
  • Active, unrestricted nursing license.
  • An outpatient coding credential—CCS, CCS-P, or CPC—is required and must be maintained during employment.
  • Nurses without a coding credential may be considered if eligible to take the exam, but must earn the credential within the first six months of employment.
  • At least five years of related healthcare experience and auditing experience with SNF, IRF, home health, DME, and hospice claims.
  • Two years of experience as a Cotiviti Clinical Validation Auditor preferred.
  • Experience with appeals, defending audit decisions, and communicating with providers.
  • Broad knowledge of medical claims billing and payment systems, provider billing rules, payer reimbursement policies, medical necessity criteria, and coding terminology.
  • Expert knowledge of official coding guidelines, Coding Clinic determinations, and CMS and other regulatory compliance guidance and mandates.
  • Working knowledge of Medicare coverage policies, medical necessity guidelines, appeals regulations, and applicable industry standards.
  • Proficiency with Word, Access, Excel, and other business applications.
  • Strong written and verbal communication skills.
  • Ability to write clear, factual, well-supported responses and communications.
  • Ability to use AI to improve efficiency and quality while independently validating all content.
  • Ability to work independently and collaboratively.
  • Must provide high-speed internet access, connectivity, and an office setup and maintain them.
  • Must provide a dedicated, secure work area.
  • Must live and work within the continental United States.
  • Flexibility and willingness to participate in an international organization’s processes, including calls across global time zones.
  • Ability to perform the duties with or without reasonable accommodation.

Imtiyozlar

  • May be considered for a discretionary bonus.
  • Nonexempt employees receive overtime pay for hours worked beyond 40 per week, or as required by state law.
  • Medical insurance.
  • Dental insurance.
  • Vision insurance.
  • Disability insurance.
  • Life insurance.
  • 401(k) savings plan.
  • Paid family leave.
  • Nine paid holidays annually.
  • 17–27 days of paid time off per year, depending on level and length of service.
  • Work-from-home arrangement.
  • Remote work requires high-speed internet access, connectivity, and an office setup, which the employee must provide and maintain.
  • Dedicated, secure work area.

O‘xshash ish o‘rinlari

BlueCross BlueShield of South Carolina

Auditor II, Medicare Cost Reporting

BlueCross BlueShield of South Carolina
HuquqKonsaltingSog‘liqni saqlash
USAmerika Qo‘shma ShtatlariALAlabamaAKAlyaskaAZArizonaCAKaliforniyaCOKoloradoCTKonnektikutFLFloridaHIGavayiIDAydahoILIllinoysIAAyovaKSKanzasKYKentukkiLALuizianaMEMenMDMerilendMAMassachusetsMIMichiganMNMinnesotaMSMissisipiMOMissuriMTMontanaNENebraskaNVNevadaNHNyu-HempshirNJNyu-JersiNMNyu-MeksikoNYNyu-YorkNCShimoliy KarolinaNDShimoliy DakotaOHOgayoOKOklaxomaOROregonPAPensilvaniyaRIRod-AylendSCJanubiy KarolinaSDJanubiy DakotaTNTennessiTXTexasUTYutaVTVermontVAVirjiniyaWAVashingtonWIViskonsinWYVayoming
49 447 $ – 94 737 $ / yil
MasofaviyTo‘liq stavkaO‘rta darajaSeniorTalab Qilinadigan Til: inglizchaAuditor

Conducts financial, compliance, and operational audits for BlueCross Blue Shield of South Carolina, with a focus on Medicare cost reports. Evaluates controls and business risks, recommends corrective actions, and supports remote audits across the United States.

Ochish