Managers of DRG Coding & Clinical Validation Audit

Manager of DRG Coding Audit-Program/Project

The Managers of DRG Coding & Clinical Validation leads a high-performing team responsible for auditing inpatient medical records to ensure the accuracy and compliance of Diagnosis-Related Group (DRG) assignments. This role plays a critical part in identifying coding discrepancies and recoverable claim opportunities, and supporting regulatory integrity on behalf of the company and its clients.

Locations:
The selected candidate must reside within a reasonable commuting distance of the designated posting location(s):
Virginia, Indiana, Georgia, Ohio, District of Columbia (Washington, DC);
Maryland;
New Jersey, New York and Texas.

Carelon Payment Integrity is a proud member of the Elevance Health family of companies. Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending.

Note:

per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

• Sets the strategic direction for audit methodologies, oversees team development, and ensures that audits meet the industry's best practices and payer-specific requirements.
• Collaborates cross-functionally with clinical, compliance, provider engagement, and data analytics teams to align audit insights with broader program goals.
• Hires, trains, coaches, counsels, and evaluates performance of direct reports.
• Analyzes audit trends, DRG shifts, and uses financial outcomes to inform strategy.
• Plans program/project scope and design.
• Develops metrics and program/project reporting tools.
• Analyzes variance to program/project plan.
• Leads building of documentation to support business objectives and ensure consistency.
• Champions local stakeholders and tactical decision-makers.
• Suggests and develops high-quality, high-value concepts and/or process improvement and efficiency recommendations.
• Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions.

• Requires a BA/BS and minimum of 5 years experience in project/program management, process reengineering, organizational design, and/or implementation; or any combination of education and experience that would provide an equivalent background.
• Willingness to travel to worksite and other locations as necessary.

• Preferred experience includes a minimum of 5-7 years of inpatient coding or DRG auditing experience, including 2-3 years in a leadership or supervisory capacity.
• Experience working with ICD-9/10CM, MS-DRG and APR-DRG.
• Broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology.

For candidates working in person or virtually in the below location(s), the salary range for this specific position is $111,040 to $199,872. Locations:
District of Columbia (Washington, DC);
Maryland;
New Jersey and New York.

In addition to salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution. The salary offered is based on legitimate, non-discriminatory factors set by the Company. Elevance Health is committed to equal pay for equal work regardless of gender, race, or any other category protected by applicable laws.

• The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
• No amount is considered wages or compensation until earned, vested, and determinable under applicable policies and plans. Any bonus, commission, benefits, or other form of compensation remains at the Company's sole discretion unless and until paid and may be modified at the Company's discretion, consistent with the law.

Please be advised Elevance Health accepts resumes for compensation only from agencies with a signed agreement. Unsolicited resumes submitted to hiring managers are the property of Elevance Health.

Elevance Health is a health company dedicated to improving lives and communities and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, seeking leaders at all levels who are passionate about impacting our members and communities.

We are creating a culture designed to advance our strategy and support personal and professional growth. Our values and behaviors are the root of our culture. We offer a range of market-competitive total rewards including merit increases, paid holidays, PTO, incentive programs,…