Cotiviti hiring Auditor Clinical Validation OPSP Coding • Remote (Work from Home) | Himalayas
CotivitiCO

Auditor Clinical Validation OPSP Coding

Cotiviti is a solutions and analytics company that leverages clinical and financial datasets to provide insights into the performance of the healthcare system, focusing on payment accuracy, risk adjustment, quality improvement, and consumer engagement. It also serves the retail industry with data management and recovery audit services.

Cotiviti

Employee count: 5000+

Salary: 46k-95k USD

United States only

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.

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 requirements of the job change.

Qualifications

Education (required)

  • Associate or bachelor’s degree Health Information Management (RHIA or RHIT).
  • Or equivalent combination of relative work experience.

Certifications/Licenses (required)

  • 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

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.

Base compensation is paid hourly at $45.67/hour (95k annualized). This role is eligible for discretionary bonus consideration.

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.

Date of posting: 6/5/25

Applications are assessed on a rolling basis. We anticipate that the application window will close on 7/05/25, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.

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About the job

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Posted on

Job type

Full Time

Experience level

Mid-level

Salary

Salary: 46k-95k USD

Location requirements

Hiring timezones

United States +/- 0 hours

About Cotiviti

Learn more about Cotiviti and their company culture.

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Through groundbreaking technology and profound data analytics, Cotiviti is revolutionizing the economics of healthcare. The company is at the forefront of enabling healthcare organizations to deliver enhanced care at a reduced cost, thereby ensuring the quality and sustainability of the healthcare system in the United States. Cotiviti's innovative solutions are a critical foundation for healthcare payers, empowering them in their mission to lower healthcare expenditures and elevate quality through higher-performing payment accuracy, risk adjustment, quality improvement, and consumer engagement programs. By processing and analyzing billions of clinical and financial data points, Cotiviti uncovers opportunities for clients to boost efficiency and quality, ultimately leading to better care for their members. The company's commitment to responsible AI implementation is evident in its partnership with the Responsible AI Institute, aiming to develop new ways to leverage artificial intelligence to foster a high-quality and viable healthcare system. This focus on accelerating the development of innovative healthcare technologies drives advancements in data analytics, interoperability, and value-based care solutions.

Cotiviti's expertise extends to serving the retail industry with sophisticated data management and recovery audit services designed to improve business outcomes. The company's approach is rooted in a combination of advanced technology, comprehensive data analytics, and specialized expertise. This synergy allows Cotiviti to provide solutions that address payment accuracy, quality improvement, risk adjustment, and network performance management. Cotiviti's dedication to innovation is further highlighted by its recent technological advancements, such as 360 Pattern Review, which utilizes artificial intelligence to rapidly identify potential healthcare fraud, waste, and abuse, and Zero Hour Alerts, which empowers large retailers to prevent payment errors. With a global team of over 9,000 employees, Cotiviti fosters a collaborative environment where specialized and talented teams work in tandem to ensure operational efficiency and deliver services that exceed industry standards. The company's vision is to enable a high-quality and viable healthcare system, and its mission is to improve this system through its unique blend of technology, analytics, and expertise.

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