Managers of DRG Coding & Clinical Validation Audit

Manager of DRG Coding & Clinical Validation Audit

3 days ago Be among the first 25 applicants

This range is provided by Elevance Health. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

$/yr - $/yr

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.

• Hybrid 2:
  This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that 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.

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.

The Manager 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.

• 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.
• Analysis of audit trends, DRG shifts, and using 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.
• Responsible for championing local stakeholders and tactical decision‑makers.
• Suggests and develops high quality, high value concept 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, which would provide an equivalent background. Travels 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 preferred.

In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non‑discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

Elevance…