Note: The job is a remote job and is open to candidates in USA. Cotiviti is a company focused on healthcare auditing, and they are seeking an Auditor for Clinical Validation OPSP Coding. The role involves auditing outpatient and specialty claims, ensuring coding accuracy, and maintaining quality standards in medical audits.
Responsibilities
• 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
• 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
• Achieves the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation
• 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
• 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
Skills
• Associate or bachelor's degree Health Information Management (RHIA or RHIT)
• Or equivalent combination of relative work experience
• 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
Benefits
• Medical
• Dental
• Vision
• Disability
• 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.
Company Overview
• Cotiviti 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 Sponsorship
• Cotiviti has a track record of offering H1B sponsorships, with 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.