Auditor Clinical Validation (Place of Service, Short Stay & Readmission)
WFA Digital Insight
The demand for skilled clinical auditors has grown significantly, with a 25% increase in remote healthcare jobs in 2025. As the healthcare industry continues to shift towards value-based care, professionals with expertise in clinical validation are in high demand. Cotiviti, a leading provider of payment accuracy and quality solutions, is at the forefront of this trend. With a strong foundation in utilization management and case management, candidates can bring significant value to this role. Before applying, candidates should be aware of the required RN license and experience with InterQual/MCG, as well as the need for strong critical thinking and decision-making skills.
Job Description
About the Role
The Auditor Clinical Validation role at Cotiviti is a critical position that requires a deep understanding of clinical guidelines and the ability to apply them in a fast-paced, remote work environment. As a clinical auditor, you will be responsible for performing retrospective clinical chart reviews on readmission and place of service claims, utilizing nationally accepted guidelines and clinical review judgment. Your expertise will help ensure that healthcare claims are accurate and compliant with regulatory requirements.The clinical auditor will be part of a team that is dedicated to improving the quality and accuracy of healthcare claims. You will work closely with other auditors, clinicians, and operational teams to identify areas for improvement and implement process changes that enhance the overall quality of care. With a strong focus on critical thinking and decision-making, this role requires a high degree of autonomy and the ability to work independently in a remote setting.
What You Will Do
- Perform retrospective clinical chart reviews on readmission and place of service claims
- Utilize nationally accepted guidelines and clinical review judgment to make informed decisions
- Access proprietary systems to audit medical records and apply critical thinking skills
- Accurately document findings and supporting references
- Identify potential claims outside of the concept where additional recoveries may be available
- Develop high-quality, high-value concepts and process improvements
- Complete special projects and other duties as assigned
- Meet or exceed standards for productivity, accuracy, and quality
- Utilize Cotiviti proprietary auditing systems with a high level of proficiency
- Generate audit letters and reports
- Collaborate with other teams to implement process improvements
What We Are Looking For
- Associate's or Bachelor's degree in nursing
- Active and unrestricted RN license in the state of residence
- 5-7+ years of experience in utilization management or case management
- Experience working with InterQual/MCG (Inpatient vs Observation)
- Critical care background (ICU, Emergency Room, Cath Lab, Med Surg)
- Proficiency in Word, Access, Excel, TEAMS, and other applications
- Excellent written and verbal communication skills
- Strong critical thinking and decision-making skills
- Ability to work in a fast-paced, remote environment
Nice to Have
- Case Management Certification
- Experience with Cotiviti proprietary auditing systems
- Knowledge of industry-based standards and regulations
- Experience working in a team environment
Benefits and Perks
- Competitive hourly rate ($45.67 per hour)
- Eligible for discretionary bonus consideration
- Overtime pay for hours worked in excess of 40 hours per week
- Comprehensive benefits package, including health, dental, and vision insurance
- Remote work stipend and home office setup reimbursement
- Paid time off and holidays
- Professional development opportunities and training programs
How to Stand Out
- Develop a strong understanding of clinical guidelines and regulations to excel in this role.
- Showcase your critical thinking and decision-making skills through specific examples in your resume and cover letter.
- Highlight your experience with InterQual/MCG and other auditing systems to demonstrate your technical expertise.
- Be prepared to discuss your experience working in a fast-paced, remote environment and how you stay organized and motivated.
- Research Cotiviti's proprietary auditing systems and be prepared to ask informed questions during the interview process.
- Emphasize your ability to work independently and as part of a team, and provide examples of times when you had to collaborate with others to achieve a goal.
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