DRG Validation Auditor – Off Hours Work

Cotiviti

. Audit inpatient claims for prepay and retrospective audits .

Posted 10/27/2026full-timeRemote • United StatesMid-LevelSenior💰 $46 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in ICD-10 coding, DRG validation, and medical claims auditing, ensuring compliance with coding guidelines and quality standards. Proficient in utilizing auditing systems and maintaining productivity while delivering high-quality audit outcomes.

Highest-signal resume keywords

ICD-10 Coding ExpertiseDRG ValidationClaims AuditingRHIA/RHIT CertificationMedical Claims Billing Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

ICD-9/10CMMS-DRGAP-DRGAPR-DRGCPT CodesHCPCS CodesCoding Guidelines AdherenceClinical ReviewAudit DeterminationsQuality Assurance

Soft Skills

Excellent Written CommunicationExcellent Verbal CommunicationAbility to Work Independently

Tools & Technologies

Cotiviti Auditing SystemsWordAccessExcelTEAMS

Certifications & Qualifications

RHIARHITCPCCCSCICCDIPCCDS

Industry Keywords

Medical Necessity CriteriaPayer Reimbursement PoliciesProvider Billing GuidelinesRegulatory ComplianceClinical Guidelines

About the role

Key responsibilities & impact

Audit inpatient claims for prepay and retrospective audits
Perform DRG Validation and make determinations without a medical record
Conduct clinical review focused on coding accuracy, treatment setting, services delivered, and patient history
Integrate medical chart coding principles, clinical guidelines, and objectivity into medical audit activities
Use advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions
Utilize Cotiviti proprietary auditing systems to make audit determinations and generate audit letters
Maintain productivity goals set by audit operations management
Meet accuracy and quality standards for valid claim identification and documentation, including letter writing
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 and special projects or other assigned duties

Requirements

What you’ll need

Associate or bachelor’s degree in nursing with an active/unrestricted license
Associate or bachelor’s degree in Health Information Management with RHIA or RHIT
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 coding/CDI certification, maintained as a condition of employment: RHIA, RHIT, CPC, CCS, CIC, CDIP, or CCDS
5 to 7+ years 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, 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 work independently
Ability to work off-hour shifts from 3 PM-11 PM or 11 PM-7 AM ET, including weekends and holidays
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 with Cotiviti
Overtime pay for hours worked in excess of 40 hours in a given week, or as otherwise required by applicable state law
Remote work arrangement
Dedicated, secure work area and high-speed internet access/connectivity and office setup and maintenance provided by the candidate