[Remote] DRG Validation Auditor (Clinical & Coding)

Note: The job is a remote job and is open to candidates in USA. Cotiviti is a healthcare auditing company, and they are seeking a DRG Validation Auditor to focus on Coding & Clinical Chart Validation for inpatient audits. The role involves auditing inpatient claims, ensuring coding accuracy, and documenting audit results while utilizing proprietary auditing systems.ResponsibilitiesAnalyzes 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 independentlyEffectively Utilizes Audit Tools. Utilizes Cotiviti proprietary auditing systems with a high level of proficiency to make audit determinations and generate audit lettersMeets or Exceeds Standards/Guidelines for Productivity. Maintains production goals set by the audit operations management teamMeets 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 TypesIdentifies potential claims outside of the concept where additional recoveries may be availableSuggests and develops high quality, high value concept and or process improvement, tools, etcComplete all responsibilities as outlined on annual Performance PlanComplete all special projects and other duties as assignedMust be able to perform duties with or without reasonable accommodationSkillsAssociate 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 environmentRHIA or RHIT certificationCPC certificationInpatient Coding Credential – CCS, CIC, CDIP or CCDS5 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 terminologyAdherence to official coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines and mandatesRequires expert coding knowledge - DRG, APRDRG, ICD-10, CPT, HCPCS codesRequires working knowledge of and applicable industry-based standardsProficiency in Word, Access, Excel, TEAMS, and other applicationsExcellent written and verbal communication skillsCommunicating with others to exchange informationAssessing the accuracy, neatness, and thoroughness of the work assignedRemaining in a stationary position, often standing or sitting for prolonged periodsRepeating motions that may include the wrists, hands, and/or fingersMust be able to provide a dedicated, secure work areaMust be able to provide high-speed internet access/connectivity and office setup and maintenanceNo adverse environmental conditions expectedBenefitsMedicalDentalVisionDisabilityLife insurance coverage401(k) savings plansPaid family leave9 paid holidays per year17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti.Company OverviewCotiviti enables healthcare organizations to deliver better care at lower cost through advanced technology and data analytics that improve the quality and sustainability of healthcare in the United States. It was founded in 1979, and is headquartered in South Jordan, UT, US, with a workforce of 5001-10000 employees. Its website is http://www.cotiviti.com.Company H1B SponsorshipCotiviti has a track record of offering H1B sponsorships, with 23 in 2026, 165 in 2025, 118 in 2024, 90 in 2023, 102 in 2022, 72 in 2021, 67 in 2020. Please note that this does not guarantee sponsorship for this specific role.