Atlanta, Georgia

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.

Key Responsibilities:

  • Audits Outpatient and Specialty Claims:
    • Utilizes medical chart coding principles and client specific guidelines in performance of medical audit activities with Outpatient and Specialty (SNF, IRF HH) claims.
    • Draws on advanced clinical 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 with advanced proficiency, Cotiviti encoder and audit tools required to perform duties.
    • Enters the 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.


  • RN or LPN License required (active / unrestricted in state of residence)
  • Coding Certification required and maintained i.e. CPC, CIC, CCS, RHIA or RHIT

Skills and Experience

  • 3 - 5 years' professional experience in providing direct patient care.
  • 3 to 5+ years related healthcare experience working with one or more of the following disciplines: SNF, IRF, APC, Home Health, ER, Diagnostics and Professional Service coding reviews.
  • A broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.
  • Minimum of 3 years of experience with clinical medical record coding or auditing and a working knowledge of HIPAA Privacy and Security Rules and CMS security requirements.
  • 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.

Work Environment

  • Start date for this role will be 2/22/2021.
  • This role is aligned to certain productivity & quality metrics
  • This is a work at home position (US only). Access to high speed internet is required (all other equipment will be provided).
  • Must be able to sit and use a computer keyboard for extended periods of time
  • Must have flexibility and willingness to participate in the work processes of an international organization, including conference calls scheduled to accommodate global time zones.
  • For the safety of our employees and those considering employment with Cotiviti, we are currently conducting all interviews virtually. In addition, the majority of the Cotiviti team is currently working remotely, and we are onboarding new hires remotely as well. As we monitor the pandemic, these arrangements may change and we will update accordingly.


Atlanta, Georgia

Cotiviti is a leading solutions and analytics company that leverages unparalleled clinical and financial datasets to deliver deep insight into the performance of the healthcare system. These insights uncover new opportunities for healthcare organizations to collaborate to improve their financial performance, reduce inefficiency, and improve healthcare quality.

We focus on improving the financial and quality performance of our clients. In healthcare, this means taking in billions of clinical and financial data points, analyzing them, and then helping our clients discover ways they can improve efficiency and quality. In addition, we support retail and life/legal industries with data management and recovery audit services.

Cotiviti applies deep data science and market expertise to help healthcare organizations in three critical areas:

·        Payment Accuracy: analyzing data flowing between payers and providers to ensure that claims are paid appropriately

·        Risk Adjustment: ensuring that health plans accurately capture and report how sick their members are so that plans are appropriately reimbursed for the healthcare services their members receive

·        Quality and Performance: evaluating healthcare cost, quality, and utilization at individual, provider, and population levels to identify the best opportunities for financial and clinical performance improvement

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