Associate Auditor Clinical Validation DRG

This auditing role will focus on Coding & Clinical Chart Validation for our Inpatient audits. The ideal candidate for this position needs to have both a clinical (nurse) and a coding / auditing background focused on the following disciplines from a coding and billing perspective: Inpatient DRG/APR-DRG and/or episode of care. This position is responsible for auditing inpatient claims and documenting the results of those audits, with a focus on clinical review, coding accuracy, and the appropriateness of treatment setting and services delivered.

Analyzes and Audits Claims. Integrates medical chart coding principles, clinical guidelines and objectivity in performance of medical audit activities. Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions. This review may include medical record review and/or episode of care reviews. Performs work independently.
• Effectively Utilizes Audit Tools. Utilizes Cotiviti proprietary auditing systems with a high level of proficiency to make audit determinations and generate audit letters.
• Meets or Exceeds Standards/Guidelines for Productivity. Maintains production goals set by the audit operations management team.
• Meets or Exceed Standards/Guidelines for Accuracy and Quality. Achieves the expected level of accuracy and quality set by the audit for the auditing concept, for valid claim identification and documentation (letter writing).
• Identifies New Claim Types. Identifies potential claims outside of the concept where additional recoveries may be available. Suggests and develops high quality, high value concept and or process improvement, tools, etc.
• Complete all responsibilities as outlined in the annual performance review and/or goal setting.
• Complete all special projects and other duties as assigned.
• Must be able to perform duties with or without reasonable accommodation.

This job description is intended to describe the general nature and level of work being performed and is not to be construed as an exhaustive list of responsibilities, duties and skills required. This job description does not constitute an employment agreement and is subject to change as the needs of Cotiviti and requirements of the job change.

Education (at least one of the following are required)

• Associate or bachelor's degree in nursing (active /unrestricted license).
• Associate or bachelor's degree Health Information Management (RHIA or RHIT).
• Licensed Practical Nurse (LPN) (active /unrestricted license).

Coding/CDI Certification (at least one of the following are required and are to be maintained as a condition of employment).

• RHIA or RHIT.
• CPC or COC.
• Inpatient Coding Credential - CCS, CIC, CDIP or CCDS.
• Candidates without a current or active coding credential must obtain one within 6 months of hire.

Experience

• 2 years of prior clinical and/or coding experience is preferred.
• Basic to Intermediate knowledge of medical and coding terminology.
• Working knowledge of medical claims billing/payment systems and provider billing guidelines is preferred.
• Requires working knowledge of and applicable industry-based standards.
• Proficiency in Word, Access, Excel, TEAMS, and other applications.
• Excellent written and verbal communication skills.

Cognitive/Mental Requirements:

• Communicating with others to exchange information.
• Assessing the accuracy, neatness, and thoroughness of the work assigned.

Working Conditions and Physical Requirements:

• Remaining in a stationary position, often standing or sitting for prolonged periods.
• Repeating motions that may include the wrists, hands, and/or fingers.
• No adverse environmental conditions expected.
• Must be able to provide a dedicated, secure work area.
• Must be able to provide high-speed internet access/connectivity and office setup and maintenance.

Base compensation is paid hourly at $31.25 to $40.86 per hour. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. This role is eligible for discretionary bonus consideration.

Nonexempt employees are eligible to receive overtime pay for hours worked in excess of 40 hours in a given week, or as otherwise required by applicable state law.

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.

Date of posting: 06/19/2025

Applications are assessed on a rolling basis. We anticipate that the application window will close on 08/19/2025, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.

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