DRG验证审计员（临床与编码）
DRG Validation Auditor (Clinical & Coding)
岗位概述
本审计职位将专注于住院患者审计（DRG验证）中的编码与临床病历验证。理想的候选人需要具备临床（护士）和编码/审计背景，重点关注以下从编码和收费角度出发的领域：住院DRG/APR-DRG。该职位负责审计住院索赔，并记录审计结果，重点在于临床审查、编码准确性以及治疗场所和服务的适当性。
入职日期为2026年8月31日或2026年10月5日
职责
- 分析并审计索赔。将医疗病历编码原则、临床指南和客观性融入医疗审计工作中。利用高级的ICD-10编码专业知识、临床指南和行业知识来支持结论。能够独立完成工作。
- 有效使用审计工具。熟练使用Cotiviti专有的审计系统，进行审计判断并生成审计信函。
- 达到或超过生产率标准/指南。保持审计运营管理团队设定的生产目标。
- 达到或超过准确性和质量标准/指南。在审计概念、有效索赔、识别和文档（信函撰写）方面达到预期的准确性和质量水平。
- 识别新的索赔类型。
- 识别超出概念范围的潜在索赔，可能有额外追回机会。
- 建议并开发高质量、高价值的概念和/或流程改进、工具等。
- 完成年度绩效计划中列出的所有职责。
- 完成所有特殊项目和其他指派的任务。
- 能够在无需合理调整或需要合理调整的情况下履行职责。
- 完成年度绩效计划中列出的所有职责。
- 完成所有特殊项目和其他指派的任务。
- 能够在无需合理调整或需要合理调整的情况下履行职责。
本职位描述旨在描述正在执行工作的总体性质和级别，不应被理解为对所需职责、任务和技能的详尽列表。本职位描述不构成雇佣协议，随着Cotiviti的需求和职位要求的变化，可能会进行更改。
资格
教育（至少满足以下一项）
查看英文原文
Overview
This auditing role will focus on Coding & Clinical Chart Validation for our Inpatient audits (DRG Validation). The ideal candidate for this position needs to have both a clinical (nurse) and a coding / auditing background focused on the following disciplines from a coding and billing perspective: Inpatient DRG/APR-DRG. This position is responsible for auditing inpatient claims and documenting the results of those audits, with a focus on clinical review, coding accuracy, and the appropriateness of treatment setting and services delivered.
Start date is 8/31/2026 or 10/5/2026
Responsibilities
- Analyzes 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 independently.
- Effectively Utilizes Audit Tools. Utilizes Cotiviti proprietary auditing systems with a high level of proficiency to make audit determinations and generate audit letters.
- Meets or Exceeds Standards/Guidelines for Productivity. Maintains production goals set by the audit operations management team.
- Meets 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 Types.
- Identifies potential claims outside of the concept where additional recoveries may be available.
- Suggests and develops high quality, high value concept and or process improvement, tools, etc.
- 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.
- 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 the requirements of the job change.
Qualifications
Education (at least one of the following are required):
- Associate 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 environment.
Coding/CDI Certification (at least one of the following are required and are to be maintained as a condition of employment):
- RHIA or RHIT.
- CPC.
- Inpatient Coding Credential – CCS, CIC, CDIP or CCDS.
Experience (required):
- 5 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 terminology.
- Adherence to official coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge - DRG, APRDRG, ICD-10, CPT, HCPCS codes.
- Requires working knowledge of and applicable industry-based standards.
- Proficiency in Word, Access, Excel, TEAMS, and other applications.
- Excellent written and verbal communication skills.
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.
Base compensation is paid hourly at $45.67 per hour (95k annualized). 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.
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: 7/22/2026
Applications are assessed on a rolling basis. We anticipate that the application window will close on 9/22/2026, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.
#senior
Originally posted on Himalayas