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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical claims auditing, appeals processes, and coding principles, with a strong focus on compliance with CMS regulations and payer guidelines. Proficient in constructing detailed appeal responses and providing educational feedback to enhance audit accuracy and efficiency.
Highest-signal resume keywords
Active/Unrestricted Nursing LicenseOutpatient Coding Credential (CCS, CCS-P, CPC)Five+ Years of Healthcare ExperienceExpert Knowledge of Official Coding GuidelinesProficiency in Word, Access, Excel
About the role
Key responsibilities & impact- Defend Cotiviti recovery determinations and appeals for SNF, IRF, home health, DME, and hospice claims
- Review appealed outpatient and specialty claims using medical chart coding principles, client-specific guidelines, and appeals guidelines
- Review initial claims, associated documentation, and additional provider-submitted appeal information
- Interpret medical records and apply coding principles, medical necessity criteria, and appeals regulations to render determinations
- Construct factual, reference-supported, grammatically correct, claim-specific appeal responses to providers
- Use Cotiviti encoder and audit tools and accurately enter appeal claims into Cotiviti systems
- Maintain production, accuracy, quality, productivity, and service-level standards
- Provide educational feedback to initial audit teams and QA based on appeal determinations
- Suggest and implement appeals concepts, process improvements, and technological improvements
- Research disputes involving MAC determinations, LCDs, NCDs, and MAC-specific billing/documentation requirements
- Compare MAC guidance with CMS manuals, regulations, and Cotiviti policy to identify conflicts or gaps
- Prepare organized findings, supporting documentation, escalations, and communications with MACs, payers, and clients
- Track MAC decisions and trends and flag recurring issues to leadership
- Support cases advancing to the Administrative Law Judge level of appeal
- Prepare case summaries, clinical timelines, position papers, medical-record excerpts, policy citations, and hearing exhibits
- Identify case strengths and weaknesses, anticipate provider arguments, and prepare rebuttals
- Assist legal, compliance, or hearing staff with research, fact-checking, and clinical/coding rationale
- Contribute to hearing preparation, including pre-hearing discussions and serving as a clinical and coding resource
- Flex into QA auditor or initial auditor roles as business needs require
- Complete assigned special projects and other duties
Requirements
What you’ll need- Associate's or Bachelor's degree in Nursing
- Active/unrestricted nursing license
- Outpatient Coding Credential required and maintained as a condition of employment: CCS, CCS-P, or CPC
- Nurses without coding certification may be considered if eligible to sit for the credential, but must obtain it within the first six months of employment
- Five+ years of related healthcare experience and auditing experience working with SNF, IRF, Home Health, DME, and Hospice claims
- Two years 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
- Expert knowledge of official coding guidelines, Coding Clinic determinations, CMS and other regulatory compliance guidelines and mandates
- Working knowledge of Medicare coverage policies, medical necessity guidelines, appeals regulations, and applicable industry-based standards
- Proficiency in Word, Access, Excel, and other business applications
- Excellent written and verbal communication skills
- Ability to construct clear, factual, well-supported written responses and communications
- Ability to use AI to improve efficiency and quality while independently validating all content
- Ability to work independently and in team environments
- Must provide high-speed internet access/connectivity and office setup and maintenance
- Must provide a dedicated, secure work area
- Must live/work within the continental United States
- Flexibility and willingness to participate in processes of an international organization, including calls across global time zones
- Must be able to perform duties with or without reasonable accommodation
Benefits
Comp & perks- Discretionary bonus consideration
- Overtime pay for nonexempt employees for hours worked over 40 per week, or as required by state law
- Medical insurance
- Dental insurance
- Vision insurance
- Disability insurance
- Life insurance
- 401(k) savings plan
- Paid family leave
- Nine paid holidays per year
- 17–27 days of Paid Time Off (PTO) per year, depending on level and length of service
- Work-from-home arrangement
- High-speed internet access/connectivity and office setup and maintenance required for remote work
- Dedicated, secure work area
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Chart Coding PrinciplesClaims Review and AppealsCoding TerminologyMedical Necessity CriteriaAudit Determinations DefenseClinical ValidationProvider CommunicationsResearch and Fact-CheckingCase Summaries PreparationRebuttal Preparation
Soft Skills
Excellent Written CommunicationExcellent Verbal CommunicationAbility to Work IndependentlyTeam CollaborationFlexibility
Tools & Technologies
Cotiviti EncoderAudit ToolsCotiviti SystemsBusiness Applications
Certifications & Qualifications
Associate's or Bachelor's Degree in NursingOutpatient Coding Credential (CCS, CCS-P, CPC)
Industry Keywords
SNF ClaimsIRF ClaimsHome Health ClaimsDME ClaimsHospice ClaimsMAC DeterminationsLCDsNCDsPayer Reimbursement PoliciesCMS Regulations