DRG Coding Auditor; Icd-Cm, Ms-Drg, Ap-Drg, -Drg

Overview

Anticipated End Date:

Position Title: DRG Coding Auditor (ICD-9/10CM, MS-DRG, AP-DRG, APR-DRG)

Job Description: Be Part of an Extraordinary Team. 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. Build the Possibilities. Make an Extraordinary Impact.

Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

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. Alternate locations may be considered if candidates reside within a commuting distance from an office.

• Auditing inpatient medical records and generating high quality recoverable claims for the company and its clients across all lines of business.
• Performing clinical reviews of medical records and other documentation to evaluate coding and DRG assignment accuracy, with a focus on DRG coding via medical records and attending physician statements from acute care hospitals.
• Analyzing and auditing claims by integrating medical chart coding principles, clinical guidelines and objectivity in medical audit activities.
• Drawing on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions.
• Utilizing audit tools and workflow systems to make audit determinations and generate audit findings letters.
• Maintaining accuracy and quality standards for auditing concepts, valid claim identification, and documentation (e.g., letter writing).
• Identifying new claim types by spotting potential claims outside of the concept where additional recoveries may be available (e.g., readmissions, inpatient to outpatient, HACs).
• Suggesting and developing high quality, high value process improvements and efficiency recommendations.

• Requires at least one of the following: AA/AS or a minimum of 5 years of experience in claims auditing, quality assurance, or recovery auditing.
• Requires at least one of the following certifications: RHIA, RHIT, CCS, or CIC.
• Requires 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG.

• BA/BS preferred.
• Experience with vendor-based Diagnosis-Related Group (DRG) Coding/Clinical Validation Audit setting or hospital coding or quality assurance environment preferred.
• Broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology preferred.
• Knowledge of plan policies and procedures in all facets of benefits management with emphasis in negotiation preferred.

For candidates working in person or virtually in the below location(s), the salary range for this specific position is $95,172 to $149,556.

Location(s): Colorado;
Illinois;
Maryland;
Minnesota;
Nevada

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 a number of factors set by the Company. The Company is committed to equal pay opportunities for equal work regardless of gender, race, or any other category protected by applicable laws.

Job Level: Non-Management Exempt

Workshift:

Job Family: MED >
Licensed/Certified - Other

The health of our associates and communities is a top priority. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual, associates are required to work at an Elevance Health location at least once per week. Vaccination policies may apply for certain roles; acceptance or accommodation will be handled per policy and law. Elevance Health is an Equal Employment Opportunity employer.

Qualified applicants will be considered without regard to age, citizenship status, color, creed, disability, ethnicity, gender identity, gender expression, marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status protected by law. Applicants requiring accommodation may contact reelevancehealthj for assistance. Qualified applicants with arrest or conviction records will be considered in accordance with laws.