Auditor Clinical Validation DRG

Auditor Clinical Validation DRG Job Locations US-Remote ID 2026-19252 Category Audit - Healthcare Position Type Full-Time Overview This auditing role will focus on Coding and 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. 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. Responsibilities 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. 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 on annual Performance Plan. * Complete all special projects and other duties as assigned. * Must be able to perform duties with or without reasonable accommodation. * Complete all responsibilities as outlined on annual Performance Plan. * 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 the requirements of the job change. Qualifications 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). * High school diploma or GED plus equivalent experience of 5+ years' experience in claims auditing, quality assurance, or recovery auditing...ideally in a DRG / Clinical Validation Audit setting or a hospital environment. 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. * Inpatient Coding Credential - CCS, CIC, CDIP or CCDS. Experience (required): * 5 to 7+ years of working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology. * Adherence to official coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge - DRG, APRDRG, ICD-10, CPT, HCPCS codes. * Requires working knowledge of and applicable industry-based standards. *... For full info follow application link. Equal Opportunit Employer/Protected Veterans/Individuals with Disabilities