<h2>Overview</h2> <p>This role is part of the training team for the Clinical Chart Validation team. This position is responsible for improving the technical effectiveness of our teams by planning, developing, and delivering technical training, mentoring, and assessment. The individual will work collaboratively with subject matter experts in the Commercial & Government Audit Teams, Quality Assurance, Concept Development, and others to validate workflows and communication tools to enhance audit productivity, performance, and client satisfaction.</p> <h2>Responsibilities</h2> <p><strong>Training, Development, and Mentoring. </strong></p> <ul> <li>Assess job-specific needs and develop technical training plans with clear business objectives, including working with subject matter experts, developing training materials, and developing appropriate assessments and measurements of success. </li> <li>Select training/instructional methods and procedures appropriate for the situation when learning or teaching new skills. </li> <li>Deliver specific training sessions, including using suitable delivery methods such as classroom, online, and webinar.  Identify the development needs of others and coach, mentor, or otherwise assist others with improving their knowledge skills.  </li> <li>Provide support to the CCV audit team members; assist with orientation of new members as needed, mentor new team members after orientation. </li> <li>Promote audit accuracy measures by training/educating and mentoring the auditor and providing documented and validated findings.</li> <li>Encourage critical thinking and discussion among team members on concepts as needed. </li> <li>Provide training on one or more of the following audit types:  <strong>Place of Service & Readmission </strong></li> <li>Confer with management and conduct surveys to identify training needs based on projected production processes, changes, and other factors. </li> <li>Participate in weekly/monthly team meetings to share best practices initiatives and recommend audit vulnerabilities. </li> <li>Support the Medical Director to ensure accurate assessments of improper payments are based on consistent application of clinical guidelines.</li> </ul> <p><strong>Assess customer/provider/stakeholder issues, complaints, and compliments.</strong></p> <ul> <li>Monitor/Assess the performance of self, other individuals, &/or organizations to make improvements or recommend remediation or corrective action. </li> <li>Work with the Quality Team to train audit team members on findings from quality review audits. </li> <li>Develop testing and evaluation procedures.  Evaluate instructor performance and the effectiveness of training programs, providing recommendations for improvements.  Conduct or arrange for ongoing technical training and personal development classes for staff members. </li> </ul> <p><strong>Quality Assurance Controls.</strong></p> <ul> <li>Integrate healthcare auditing principles and use objectivity in the performance of medical audit activities and reviews. </li> <li>Draw on healthcare proficiency and industry knowledge to substantiate conclusions. </li> <li>Perform work independently, review and interpret audit work of others. </li> <li>Depending on the nature and scope of the 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.</li> <li>Demonstrate an understanding of complex contract specifications when performing medical record reviews.</li> <li>Use healthcare expertise to determine approval or referral to the Medical Director. </li> <li>Provide feedback on reviews to the Quality Assurance Manager as indicated in order to assist with the improvement of rationales sent to providers.</li> </ul> <p><strong>New Concepts and Processes.</strong></p> <ul> <li>Develop reasonable and effective recommendations for concept solutions that reflect an understanding of the client environment and risks inherent to our business and industry.</li> <li>Suggest and or develop and implement new ideas, approaches, decision trees, and/or technological improvements that will support and optimize audit results.</li> <li>Collaborate with Data Services in developing new reports.</li> </ul> <p><strong>Meets or Exceeds Standards/Guidelines for Productivity.</strong></p> <ul> <li>In addition to regular and predictable attendance, maintain production goals and quality standards set by the audit.</li> <li>Performs QA audits against the expected level of quality and quantity (i.e. hit rate, # claims written, ID per hour).</li> </ul> <p>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 change as the needs of Cotiviti and requirements of the job change. </p> <h2>Qualifications</h2> <p><strong>Education/Certification/Licenses (required): </strong></p> <p> </p> <ul> <li>Associate or Bachelor's degree in nursing.</li> <li>RN License (active /unrestricted in state of residence).</li> <li>Case Management Certification (preferred, but not required).</li> <li>Additional certifications in Interqual or MCG (preferred, but not required)</li> </ul> <p> </p> <p><strong>Experience: </strong></p> <ul> <li>5 to 7+ years of working with InterQual/MCG (Inpatient vs Observation).</li> <li>Background in Utilization Management and/or Case Management.</li> <li>Critical Care background: ICU, Emergency Room, Cath Lab, Med Surg.</li> <li>5 to 7+ years of working with a broad knowledge of medical claims, billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.</li> <li>Adherence to official coding guidelines and other regulatory compliance guidelines and mandates. Requires expert level knowledge of Interqual and/or MCG criteria</li> <li>Strong presentation skills. Comfortable in presenting/defending audit logic to clients and key stakeholders (i.e. hospitals, physicians, validation contractors, auditing team, etc.).</li> <li>Independent thinker, logical, strategic, with a high focus and attention to detail.</li> <li>Effective communication and presentation style (written and verbal) with proven ability to positively influence behavior and outcomes.</li> <li>Knowledge of principles and methods for curriculum and training design, teaching and instruction for individuals and groups, and the measurement of training effects.</li> <li>Competent administrative and organizational skills, ability to multitask, set priorities, and meet deadlines.</li> <li>Professional demeanor:  Ability to creatively solve problems, deal with ambiguity, develop and implement policy and procedures, perform analysis and prepare reports, and foster team building. </li> <li>High level of proficiency with all audit technology i.e., R3, CAT, etc. </li> <li>Proficiency in Word, Access, Excel, PowerPoint and other applications.  </li> <li>Excellent written and verbal communication skills. </li> <li>Applicants should have home health, IRF, and SNF experience.</li> </ul> <p><strong>Mental Requirements:</strong></p> <ul> <li>Communicating with others to exchange information.</li> <li>Problem-solving and thinking critically.</li> <li>Completing tasks independently. </li> </ul> <p><strong>Physical Requirements and Working Conditions:</strong></p> <ul> <li>Remaining in a stationary position, often standing or sitting for prolonged periods.</li> <li>Repeating motions that may include the wrists, hands, and/or fingers.</li> <li>Must be able to provide a dedicated, secure work area.</li> <li>Must be able to provide high-speed internet access/connectivity and office setup and maintenance.</li> <li>No adverse environmental conditions are expected.</li> </ul> <p>Base compensation ranges from $105,000 to $125,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. This role is eligible for discretionary bonus consideration. </p> <p> </p> <p>Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti. For information about our benefits package, please refer to our Careers page.</p> <p> </p> <p>Date of posting: TBD</p> <p>Applications are assessed on a rolling basis. We anticipate that the application window will close on TBD, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.</p> <p>#LI-Remote</p> <p>#LI-JJ1 </p> <p>#Senior</p> <p>#LI-DNP </p>