Auditor DRG Validation (CMS Audits)

Auditor DRG Validation (CMS Audits) Job Locations US-Remote ID 2026-20396 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 a coding/auditing background focused on Inpatient DRG Coding from a coding and billing perspective. This position is responsible for auditing inpatient DRG and documenting the results of those audits with a focus on coding accuracy and the appropriateness of treatment setting and services delivered. This role will start on XXX Responsibilities Audits Inpatient DRG Claims: * Utilizes medical chart coding principles and client specific guidelines in performance of medical audit activities with Inpatient DRG claims. * Draws on advanced clinical expertise and industry knowledge to substantiate conclusions. * Performs work independently, reviews and interprets medical records and applies in-depth knowledge of coding principles to determine potential billing/coding issues. * 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 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 c riteria 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... For full info follow application link. Equal Opportunity Employ r/Protected Veterans/Individuals with Disabilities