Senior Auditor Appeals

Role Description

The Senior Auditor, Appeals position is part of the Clinical Chart Validation (CCV) team and is responsible for defending Cotiviti’s recovery determinations utilizing the appropriate guidelines including but not limited to Commercial, CMS inpatient and outpatient coding guidelines, coding clinics, and internal clinical validation policies if applicable. The appeals auditor is responsible for performing an extensive review of the initial claim along with the associated documentation as well as any additional information submitted by the provider on appeal. The appeals auditor will render a decision, and formulate a written response, on each claim reviewed providing the most accurate decision possible. The appeals auditor assists the team leads in providing any educational feedback appropriate for the initial audit team and QA. This person is considered a Subject Matter Expert in all CCV review types and appeals. Displays professional skepticism that enhances the work performed in order to achieve success in the role.

Responsibilities

• Utilizes all available tools and resources to evaluate each appeal reviewed.
• Applies the policies and guidelines appropriate to the claim/appeal to deliver the most accurate decision.
• Constructs factual, reference-supported responses to the provider describing reasons for the determination.
• Constructs grammatically correct, claim-specific, and professionally written responses to the providers.
• Ensures that service level agreements are met for any work assigned.
• Maintains a minimum productivity standard as outlined for the role.
• May flex into the role of the QA auditor or the initial auditor as business needs require.
• Provides educational feedback to the audit and QA team based upon appeal reviews.
• Must be able to perform duties with or without reasonable accommodation.

Qualifications

• Education (at least one of the following is required):
  • Associates or Bachelor's degree in Nursing (active/unrestricted license)
  • Associate or Bachelor's degree in Health Information Management (RHIA or RHIT)
  • Equivalent experience of 5+ years in claims auditing, quality assurance, or recovery auditing, ideally in a DRG / Clinical Validation Audit setting or a hospital environment.
• Coding Certification (at least one of the following are required and are to be maintained as a condition of employment):
  • RHIA or RHIT
  • Inpatient Coding Credential - CCS or CIC preferred.
  • Candidates who hold a CCDS or CPC will be given consideration but will need to obtain an inpatient coding certification within 1 year of their hire date with the company.

Requirements

• 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.
• 3-5 years of medical record auditing or similar experience.
• Ability to utilize and analyze clinical auditing knowledge and skills to learn and become proficient in a variety of review types such as DRG, SNF, Home Health, DME, Hospice, Readmissions, SS, and therapy reviews.
• 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.
• Requires working knowledge of and applicable industry-based standards.
• Proficiency in Word, Access, Excel, and other applications.
• Excellent written and verbal communication skills.
• Ability to work well in an individual and team environment.

Benefits

• Competitive benefits package including medical, dental, vision, disability, and 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.