DRG Clinical Validation Auditor; RN​/Claims Reviewer

Anticipated End Date

DRG Clinical Validation Auditor (RN/Claims Reviewer)

Virtual:
This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. 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 locations will not be considered for employment, unless an accommodation is granted as required by law.

The DRG Clinical Validation Auditor 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.

Primary duties may include, but are not limited to:

• 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.

• 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 strongly preferred:
  • Certified Clinical Documentation Specialist (CCDS),
  • Certified Documentation Improvement Practitioner (CDIP),
  • Certified Professional Coder (CPC) and/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.
• Bedside Acute care experience strongly 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 below locations, the salary range for this specific position is $90,000 to $135,702.

Maryland;
Nevada

Non‑Management Exempt

1st Shift (United States of America)

MED >
Licensed/Certified - Other

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 (including gender identity and gender expression), 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 elevancehealthj for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.