Auditor DRG Validation (CMS Audits) at Cotiviti in US-Remote

Job description

• This auditing role will focus on Coding & 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 11/9/2026.

Responsibilities

• 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.

Requirements

• 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.
• 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.
• Proficiency in Word, Access, Excel, TEAMS, and other applications.
• Excellent written and verbal communication skills.

Skills

Required

• Performs work independently
• ICD-9/10CM
• MS-DRG
• AP-DRG
• APR-DRG
• CPT
• HCPCS
• Word
• Access
• Excel
• TEAMS

Benefits

• 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.
• This role will start on XXX
• Base compensation is paid hourly at $45.67 per hour (95k annualized). 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.