Auditor Clinical Validation (place Of Service, Short Stay An

Auditor Clinical Validation (Place Of Service, Short Stay And Readmission)

This auditing role will be responsible for performing retrospective clinical chart reviews on readmission and place of service claims by utilizing nationally accepted guidelines, clinical review judgment and review methodologies specific to the contract for which services are being provided. This involves accessing proprietary systems to audit medical records, applying critical thinking and decision-making skills, and accurately documenting a rationale with the findings and supporting references. The ideal candidate for this role would be a registered nurse with experience in utilization or case management.

Responsibilities:

• Analyzes and Audits Claims. Integrates medical chart severity of illness and intensity of service based on clinical guidelines and objectivity in performance of medical audit activities.
• 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 Exceeds 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.

Qualifications:

• Education/Certification/Licenses (required): Associate or Bachelor’s degree in nursing, RN License (active/unrestricted in state of residence), Case Management Certification (preferred)
• Experience (required): 5 to 7+ years of working with InterQual/MCG (Inpatient vs Observation), Utilization Management and/or Case Management, Critical Care background: ICU, Emergency Room, Cath Lab, Med Surg, 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.

This role will start on January 5, 2026. Training will be throughout the month of January (no time off during this time). Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities.