Senior Auditor Appeals - OPSP

Overview The Senior Auditor, Appeals is responsible for defending Cotiviti ’s recovery determinations and appeals for skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), home health, durable medical equipment (DME), and hospice claims. The auditor applies appropriate guidelines, including Centers for Medicare & Medicaid Services (CMS) inpatient and outpatient coding guidelines, Coding Clinic guidance, and internal clinical validation policies. The auditor performs an extensive review of the initial claim, the associated documentation, and any additional information the provider submits on appeal. Working independently, the auditor interprets medical records and applies in-depth knowledge of coding principles, medical necessity criteria, and appeals regulations to render decisions and write clear, well-supported responses. The role requires both clinical (nursing) and coding/auditing expertise to substantiate appeal conclusions and support accurate determination outcomes. The auditor is also proficient in using AI-enabled tools to improve the speed, consistency, and quality of appeals work. The auditor remains accountable for every final determination and written response, follows Cotiviti policy on the responsible use of AI, and protects protected health information (PHI) and client data when using these tools. Because AI-generated content must be reviewed, edited, and fact-checked before use, the auditor exercises sound clinical and professional judg