Senior Auditor Appeals - OPSP

Overview The Senior Auditor, Appeals is responsible for defending Cotiviti’s recovery determinations and appeals for skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), home health, durable medical equipment (DME), and hospice claims. The auditor applies appropriate guidelines, including Centers for Medicare & Medicaid Services (CMS) inpatient and outpatient coding guidelines, Coding Clinic guidance, and internal clinical validation policies. The auditor performs an extensive review of the initial claim, the associated documentation, and any additional information the provider submits on appeal. Working independently, the auditor interprets medical records and applies in-depth knowledge of coding principles, medical necessity criteria, and appeals regulations to render decisions and write clear, well-supported responses. The role requires both clinical (nursing) and coding/auditing expertise to substantiate appeal conclusions and support accurate determination outcomes. The auditor is also proficient in using AI-enabled tools to improve the speed, consistency, and quality of appeals work. The auditor remains accountable for every final determination and written response, follows Cotiviti policy on the responsible use of AI, and protects protected health information (PHI) and client data when using these tools. Because AI-generated content must be reviewed, edited, and fact-checked before use, the auditor exercises sound clinical and professional judgment and never relies on AI output alone. This position is considered a subject matter expert (SME) in appeals, SNF, IRF, home health, DME, and hospice audits, Medicare coverage criteria, medical necessity guidelines, coding regulations, and appeals processes. The auditor displays professional skepticism and strong analytical skills that strengthen the appeal work performed, and stays current on emerging AI capabilities and best practices that can improve audit and appeals workflows. Responsibilities Reviews appealed outpatient and specialty claims utilizing medical chart coding principles, client-specific guidelines, and appeals guidelines. Draws on advanced clinical expertise and industry knowledge to substantiate appeal conclusions and render determinations. Performs extensive review of initial claims along with associated documentation and additional information submitted by providers on appeal. Performs work independently, reviews and interprets medical records, and applies in-depth knowledge of coding principles and medical necessity criteria to support appeal decisions. Constructs factual, reference-supported written responses to providers describing reasons for appeal determination. Constructs grammatically correct, claim-specific, and professionally written appeal responses. Utilizes with advanced proficiency all Cotiviti encoder and audit tools required to perform duties. Enters appeal claims into Cotiviti system accurately and in accordance with standard procedures. Maintains production goals, accuracy and quality standards set for the appeals concept. Achieves the expected level of quality set for valid claim identification, documentation, and appeals decisions. Assists team leads in providing educational feedback appropriate for initial audit teams and QA based on appeal determinations. Suggests and develops high-quality, high-value appeals concepts and process improvements. Possesses broad, in-depth knowledge of client contract terms, complex claim types, and appeals processes from extensive healthcare auditing experience. Suggests, develops and implements new ideas, approaches, and technological improvements that enhance appeals production, communication, and client satisfaction. Ensures that service level agreements are met for any work assigned. Maintains minimum productivity standards as outlined for the role. May flex into roles of QA auditor or initial auditor as business needs require. Complete all responsibilities as outlined in the annual performance review and/or goal setting. Complete all special projects and other duties as assigned. Must be able to perform duties with or without reasonable accommodation. Research disputes involving MAC determinations, including local coverage determinations (LCDs), national coverage determinations (NCDs), and MAC-specific billing and documentation requirements. Compare MAC guidance against CMS manuals, regulations, and Cotiviti policy to identify conflicts or gaps. Write up findings in clear, well-organized summaries that give stakeholders the facts, citations, and recommended next steps. Track MAC decisions and trends and flag recurring issues to leadership. Prepare supporting documentation for escalations and for communications with MACs, payers, and clients. Administrative law judge (ALJ) support (as needed). Support Cotiviti’s position on cases that advance to the ALJ level of appeal. Prepare case summaries, clinical timelines, and position papers that outline the basis for the original determination. Compile and organize medical record excerpts, policy citations, and supporting exhibits for hearing files. Identify the strongest and weakest points of a case, anticipate provider arguments, and prepare rebuttals. Assist legal, compliance, or hearing staff with research, fact checking, and responses to questions about clinical or coding rationale. Contribute to hearing preparation, which may include participating in pre-hearing discussions or serving as a clinical and coding resource. 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's orBachelor's degree in Nursing (active/unrestricted license). Coding Certification (Required and to be maintained as a condition of employment): Outpatient Coding Credential (CCS, CCS-P, or CPC). Nurses not currently holding coding certification but eligible to sit for the credential will be considered (must obtain within first six months of employment). Experience Required: Five+ years of related healthcare experience and auditing experience working with SNF, IRF, Home Health, DME, and Hospice claims. Twoyears of experience as a Cotiviti Auditor Clinical Validation, preferred. Experience with appeals processes, defense of audit determinations, and provider communications. 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. Working knowledge of Medicare coverage policies, medical necessity guidelines, and appeals regulations. Working knowledge of applicable industry-based standards. Proficiency in Word, Access, Excel, and other business applications. Excellent written and verbal communication skills. Ability to construct clear, factual, and well-supported written responses and communications, using AI to improve efficiency and quality while applying independent clinical and professional judgment to validate all content. Ability to work well in individual and team environments. Mental Requirements: Communicating with others to exchange information. Assessing the accuracy, neatness, and thoroughness of work assigned. Physical Requirements and Working Conditions: Remaining in a stationary position, often sitting for prolonged periods. Repeating motions that may include the wrists, hands, and/or fingers. No adverse environmental conditions expected. Must provide high-speed internet access/connectivity and office setup and maintenance. Must provide a dedicated, secure work area. This is a work-from-home position with work location required within the continental United States. Must have flexibility and willingness to participate in work processes of an international organization, including conference calls scheduled to accommodate global time zones. Compensation and Benefits: Base compensation is paid hourly at $47.75 to $57.00 per hour. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. 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, nine 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. Date of posting: 10/13/2026 Applications are assessed on a rolling basis. We anticipate that the application window will close on 11/30/2026, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.LI-Remote #LI-JJ1#senior #J-18808-Ljbffr