Auditor, DRG Validation – CMS Audits

Cotiviti

. Audit inpatient DRG claims using medical chart coding principles and client-specific guidelines .

Posted 9/21/2026full-timeRemote • United StatesMid-LevelSenior💰 $46 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in auditing inpatient DRG claims, applying advanced coding knowledge, and adhering to regulatory compliance guidelines. Proficient in utilizing auditing systems and tools to ensure accuracy and quality in claim identification and documentation.

Highest-signal resume keywords

DRG AuditingICD-9/10CM CodingRHIA CertificationClaims Auditing ExperienceMedical Claims Billing Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Chart CodingCoding TerminologyRegulatory ComplianceCPT CodingHCPCS CodingMS-DRG KnowledgeAP-DRG KnowledgeAPR-DRG KnowledgeQuality AssuranceProcess Improvement

Soft Skills

Excellent Communication SkillsAttention to DetailIndependent ReviewInformation Exchange

Tools & Technologies

Cotiviti Auditing SystemsMicrosoft WordMicrosoft AccessMicrosoft ExcelMicrosoft TEAMS

Certifications & Qualifications

RHIARHITCPCCCSCICCDIPCCDS

Industry Keywords

Health Information ManagementClaims AuditingClinical Validation AuditPayer Reimbursement PoliciesMedical Necessity Criteria

About the role

Key responsibilities & impact

Audit inpatient DRG claims using medical chart coding principles and client-specific guidelines
Review and interpret medical records independently
Apply in-depth coding knowledge to determine potential billing and coding issues
Draw on advanced clinical expertise and industry knowledge to substantiate conclusions
Use Cotiviti proprietary auditing systems to make audit determinations and generate audit letters
Meet productivity goals established by audit operations management
Meet accuracy and quality standards for valid claim identification and documentation
Identify potential claims outside the audit concept where additional recoveries may be available
Suggest and develop high-quality, high-value concepts, process improvements, and tools
Complete annual performance plan responsibilities
Complete special projects and other assigned duties

Requirements

What you’ll need

Associate or bachelor’s degree in Health Information Management (RHIA or RHIT)
Alternatively, high school diploma or GED plus 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
At least one required and maintained certification: RHIA, RHIT, CPC, CCS, CIC, CDIP, or CCDS
5 to 7+ years of experience working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG
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
Expert knowledge of DRG, APRDRG, ICD-10, CPT, and HCPCS codes
Working knowledge of applicable industry-based standards
Proficiency in Word, Access, Excel, TEAMS, and other applications
Excellent written and verbal communication skills
Ability to communicate with others to exchange information
Ability to assess the accuracy, neatness, and thoroughness of assigned work
Ability to provide a dedicated, secure work area
Ability to provide high-speed internet access/connectivity and office setup and maintenance
Ability to perform duties with or without reasonable accommodation

Benefits

Comp & perks

Discretionary bonus consideration
Medical insurance coverage
Dental insurance coverage
Vision insurance coverage
Disability insurance coverage
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
Overtime pay for hours worked in excess of 40 hours in a given week, or as otherwise required by applicable state law