Overview
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 (required)
- Associate or bachelor's degree in nursing (active /unrestricted license) AND Certifications/Licenses (required).
- Coding Certification required and maintained i.e. CPC, CIC, CCS, CCS-P, RHIA or RHIT.
- 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.
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 expected.
This role will start on 9/14/2026.
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.