Senior Auditor Quality - OPSP

Overview The Sr. Auditor, Quality Assurance position is responsible for ensuring that the audited claims meet quality standards necessary to generate high quality recoverable claims for the benefit of Cotiviti and our clients. Audited claim types include: Outpatient and Specialty Review Types to include SNF, IRF, HH, DME, Hospice and medical necessity. Quality assurance emphasizes compliance with established procedures, accuracy of claim identification and supportive documentation. Identifies and notifies management of observed quality and communicates opportunities for process improvements based on independent audit claims review. Displays professional skepticism that enhances the work performed in order to achieve success in position. Responsibilities Performs clinical quality assurance review of daily clinical validation reviews. The quality auditor will be responsible for communicating with the initial auditor when there are differing decisions on the audit to ensure that the final decision is supported and as accurate as possible. Integrates healthcare auditing principles and uses objectivity in performance of medical audit activities and review. Utilizes industry knowledge and proficiency in healthcare to substantiate decisions. Performs work independently and reviews work of others. Depending on nature and scope of audit, may review medical records and apply in-depth knowledge of clinical criteria to determine medical necessity, appropriateness of setting, potential billing/coding issues, and quality concerns. May serve as a mentor to other QA auditors or initial auditors. Depending on the business needs, may also flex into the initial audit role and/or the appeals role as needed. This job description is intended to describe the general nature and level of work being performed and is not to be construed as an exhaustive list of responsibilities, duties and skills required. This job description does not constitute an employment agreement and is subject to chan