Georgia Employer AUDITOR, CLINICAL VALIDATION in Atlanta, Georgia
JOB ID-17-1164Key ResponsibilitiesIdentifies and Enters Claims. Integrates medical chart coding principles and objectivity in performance of medical audit activities. Draws on advanced ICD-9 and ICD-10 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, and quality concerns.Effectively Utilizes Audit Tools. Utilizes with advanced proficiency, Cotiviti and client tools required to perform duties. Enters the claim into Cotiviti system accurately and in accordance with standard procedures. Updates current reports, develops and runs custom queries and validates accuracy of current reports used. Makes determinations based on prior knowledge, experience of client contract terms with the likelihood of recovery acceptance.Meets or Exceeds Standards/Guidelines for Productivity. Maintains production goals and quality standards set by the audit for the auditing concept. Audits against the expected level of quality and quantity (i.e. hit rate, # claims written, ID per hour).Meets or Exceed Standards/Guidelines for Quality. Achieves the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation.Prepares Responses to Client Disputes. Provides independent verification of claims validation, insurance or employer validation in a concise written manner.Reviews Provider Contracts. Demonstrates high level of expertise in researching requirements necessary to make recommendations on client contracts to fit projects within standard reports such as medical policies and state and federal statutes.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.Education & Work Experience Associates Degree or equivalent relevant experience required. Bachelor's degree in Nursing, Healthcare Economics, Health Information Management, and/or Business, preferred, or 5 - 7 years' experience (experience in any of the following: claims auditing/quality assurance/recovery auditing - ideally in a DRG / Clinical Validation Audit setting or hospital environment) strongly preferred.Strongly preferred Nursing education (ASN, BSN, or MSN); active, unrestricted license.Clinical /Nursing experience in an inpatient setting is a plus. Cotiviti is an Equal Opportunity Employer. The Company provides equal employment opportunities to all applicants for employment without regard to gender, sexual orientation or preference, gender identity or expression, race, color, religion, national origin, ethnicity, ancestry, age, marital status, pregnancy, childbirth or related medical conditions, mental or physical disability, veteran status or any other characteristic protected by federal, state or local law, ordinance or regulation.For more details go to URL.