Diagnosis Related Group Clinical Validation Auditor-Rn; CDI, Ms-Drg, AP-DRG and -Drg

Overview

Anticipated End Date:

Position Title: Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)

Job Description: Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG) — Virtual role with in-person training sessions as required. Alternate locations may be considered if candidates reside within a commuting distance from an office.

The Diagnosis Related Group Clinical Validation Auditor-RN is responsible for auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims.

• Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities.
• Draws on advanced ICD-10 coding expertise, mastery of clinical guidelines, and industry knowledge to substantiate conclusions.
• Utilizes audit tools, auditing workflow systems and reference information to generate audit determinations and formulate detailed audit findings letters.
• Maintains accuracy and quality standards as established by audit management.
• Identifies potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate billing for readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs).
• Suggests and develops high quality, high value, concept and/or process improvement and efficiency recommendations.

• Requires current, active, unrestricted Registered Nurse license in applicable state(s).
• Requires a minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement, and a minimum of 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG; or any combination of education and experience, which would provide an equivalent background.

• One or more of the following certifications are preferred: RHIT, RHIA, CCDS, CDIP, CPC or Inpatient Coding Credential such as CCS or CIC.
• Experience with third party DRG Coding and/or Clinical Validation Audits or hospital clinical documentation improvement experience preferred.
• Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred.

For candidates working in person or virtually in the listed locations, the salary range for this position is $81,852 - $155,088.

Locations:
California;
Colorado;
District of Columbia (Washington, DC), Illinois, Maryland, Minnesota, Nevada;
New York;
Washington State.

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company seeking leaders at all levels who are passionate about making an impact on our members and the communities we serve.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender, marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact Elevance Health for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.