• Assess job-specific needs and develop technical training plans with clear business objectives • Select training/instructional methods and procedures appropriate for the situation • Deliver specific training sessions, including using suitable delivery methods such as classroom, online, and webinar • Identify the development needs of others and coach, mentor, or otherwise assist others with improving their knowledge skills • Provide support to the CCV audit team members; assist with orientation of new members as needed • Promote audit accuracy measures by training/educating and mentoring the auditor and providing documented and validated findings • Conduct or arrange for ongoing technical training and personal development classes for staff members • Integrate healthcare auditing principles and use objectivity in the performance of medical audit activities and reviews • Provide feedback on reviews to the Quality Assurance Manager as indicated

Role Description The Senior Auditor, Appeals position is part of the Clinical Chart Validation (CCV) team and is responsible for defending Cotiviti’s recovery determinations utilizing the appropriate guidelines including but not limited to Commercial, CMS inpatient and outpatient coding guidelines, coding clinics, and internal clinical validation policies if applicable. - Perform an extensive review of the initial claim along with the associated documentation and any additional information submitted by the provider on appeal. - Render a decision and formulate a written response on each claim reviewed providing the most accurate decision possible. - Assist team leads in providing educational feedback appropriate for the initial audit team and QA. - Considered a Subject Matter Expert in all CCV review types and appeals. - Display professional skepticism that enhances the work performed to achieve success in the role. - Utilize all available tools and resources to evaluate each appeal reviewed. - Apply the policies and guidelines appropriate to the claim/appeal to deliver the most accurate decision. - Construct factual, reference-supported responses to the provider describing reasons for the determination. - Construct grammatically correct, claim-specific, and professionally written responses to the providers. - Ensure that service level agreements are met for any work assigned. - Maintain a minimum productivity standard as outlined for the role. - May flex into the role of the QA auditor or the initial auditor as business needs require. - Provide educational feedback to the audit and QA team based upon appeal reviews. - Must be able to perform duties with or without reasonable accommodation. Qualifications - Education (at least one of the following is required): - Associates or Bachelor's degree in Nursing (active/unrestricted license) - Associate or Bachelor's degree in Health Information Management (RHIA or RHIT) - Equivalent experience of 5+ years in claims auditing, quality assurance, or recovery auditing, ideally in a DRG / Clinical Validation Audit setting or a hospital environment. - Coding Certification (at least one of the following are required and are to be maintained as a condition of employment): - RHIA or RHIT - Inpatient Coding Credential - CCS or CIC preferred. - Candidates who hold a CCDS or CPC will be given consideration but will need to obtain an inpatient coding certification within 1 year of their hire date with the company. Requirements - 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. - 3-5 years of medical record auditing or similar experience. - Ability to utilize and analyze clinical auditing knowledge and skills to learn and become proficient in a variety of review types such as DRG, SNF, Home Health, DME, Hospice, Readmissions, SS, and therapy reviews. - 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. - Requires working knowledge of and applicable industry-based standards. - Proficiency in Word, Access, Excel, and other applications. - Excellent written and verbal communication skills. - Ability to work well in an individual and team environment. Benefits - Competitive benefits package 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.

Role Description Under the Quality Improvement Department, the Quality Care Auditor reviews client records to evaluate the documentation justifying service necessity, compliance with federal and state guidelines, accreditation standards, and ABHS policy. This position assists with the provision of scheduled training on documentation and will also assist with the preparation for and facilitation of external fidelity audits and other compliance reviews. Assists with input of data and generates reports to document errors and trends. Performs daily tasks with minimal supervision. Job Responsibilities and Performance Standards - Serves as clinical resource in Behavioral Health/Addictive Disease & Intellectual Developmental Disability Practices to ensure compliance with regulations, standards, and policies. - Conducts internal audits to include Peer and Quality Reviews. - Conducts internal audits to ensure Programmatic Integrity based on ERO (External Review Organization) and agency standards. - Assists with audits and reviews of agency oversights and payors. - Identifies trends, training needs, and areas for improvement. - Collaborates with Quality Care Coordinator to develop new training for various types of staff. - Reviews clinical documentation (e.g. assessment, progress note, treatment plan) for required ERO and agency standards and communicates with supervisors and staff to identify training needs. - Performs internal audits, including quarterly peer reviews and monthly quality reviews, using established criteria to determine specific and overall issues related to compliance and/or training needs. Shares information with responsible clinician/supervisor and assists in formulating plans for correction/training. - Maintains a good working relationship with physicians/clinicians/admin support/business office and others to keep them informed about new rules and regulations. - Acknowledges and responds to requests for information in a timely manner. Attends regular agency and program staff meetings to disseminate information and provides support. - Other duties as assigned by Quality Care Coordinator. Qualifications - Master’s degree in counseling, social work, psychology, or closely related field and 2+ years of professional experience in a Behavioral Health/Addictive Disease/Intellectual Developmental Disabilities setting. - Knowledge of DBHDD provider manual and guidelines. - Proficient use of Electronic Health Record systems. Preferred Qualifications - Full licensure and/or certification in one or more counseling, social work fields. - Proficient use of Microsoft applications (Excel, Power Point, Word).

• Systematic review of anesthesia records to ensure accuracy, completeness, and compliance with regulatory and institutional standards • Verifying that all required documentation, provider signatures, and charges are present and appropriately supported • Supporting quality assurance and regulatory compliance within the anesthesia department • Assisting with other auditor duties as assigned • Monitoring, tracking, and reporting recurring errors or documentation trends to providers for process improvement initiatives • Collaborating with billing, compliance, and clinical departments to address documentation, regulatory, and process-related needs • Conducting detailed audits to ensure all charges are captured, supported by orders, and appropriately documented