Role Description This auditing role will focus on Coding & Clinical Chart Validation for our Outpatient and Specialty audits. The ideal candidate for this position needs to have both a clinical (nurse) and a coding/auditing background focused on one of the following disciplines from a coding and billing perspective: SNF, IRF, Home Health, APC, ER, Diagnostics and Professional Service. This position is responsible for auditing outpatient/specialty claims and documenting the results of those audits with a focus on clinical review, coding accuracy, medical necessity, and the appropriateness of treatment setting and services delivered. Responsibilities - Audits Outpatient and Specialty Claims - Utilizes medical chart coding principles and client specific guidelines in performance of medical audit activities with Outpatient (APC, PNPP), Pharmacy and/or Inpatient DRG claims. - Draws on advanced coding 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 advanced proficiency, Cotiviti encoder and audit tools required to perform duties. - Enters claim into Cotiviti system accurately and in accordance with standard procedures. - Meets or Exceeds Standards/Guidelines for Productivity - Maintains production goals, accuracy, and quality standards set by the audit for the auditing concept. - Meets or Exceeds Standards/Guidelines for Quality - Achieves the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation. - Identifies New Claim Types - Identifies potential claims outside of the concept where additional recoveries may be available. - Suggests and develops high quality, high value concepts and/or processes improvement, tools, etc. - Recommends New Concepts and Processes - Has broad in-depth knowledge of client, contract terms and complex claim types gained from extensive healthcare auditing experience. - Suggests, develops and implements new ideas, approaches and/or technological improvements that will support and enhance audit production, communication and client satisfaction. - Evaluates information and draws logical conclusions. - 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. Qualifications - Education: Associate or bachelor’s degree in Health Information Management (RHIA or RHIT) or equivalent combination of relative work experience. - Certifications/Licenses: Coding Certification required and maintained i.e. CPC, CIC, CCS, CCS-P, RHIA or RHIT. - Experience: 5 to 7 years of experience with clinical medical record coding or auditing and a working knowledge of HIPAA Privacy and Security Rules and CMS security requirements. - Working knowledge of HIPAA Privacy and Security Rules, CMS security requirements and clinical medical record coding or auditing. - A broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology. - Ability and desire to utilize base coding and clinical auditing knowledge to learn and become proficient in a variety of outpatient and specialty review types. - Adherence to official coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines and mandates. - Requires expert coding knowledge - DRG, ICD-10, CPT, HCPCS codes. - Excellent verbal and written communication skills. - Ability to work well in an individual and team environment. Requirements - Mental Requirements: Communicating with others to exchange information. - Assessing the accuracy, neatness, and thoroughness of the work assigned. - Physical Requirements and Working Conditions: Remaining in a stationary position, often standing or sitting for prolonged periods. - Repeating motions that may include the wrists, hands, and/or fingers. - 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. - No adverse environmental conditions are expected. Benefits - Base compensation is paid hourly at $45.67/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. - 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. - 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti.