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

Overview

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

Note:

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.

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. This role 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 credentials 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 locations below, the salary range for this specific position is $81,852 to $155,088.

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

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 and is contingent on eligibility requirements. Elevance Health is committed to equal pay opportunities for equal work regardless of protected status.

The salary range is Elevance Health's good faith range of possible compensation at the time of posting. This range may be modified in the future and actual compensation may vary based on location, experience, education, and skill. Details regarding bonuses, benefits, or other compensation remain at the Company’s discretion.

Elevance Health operates 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 onsite requirements will be discussed during the hiring process.

The health of our associates and communities is a priority. Some patient/member-facing roles require vaccination against COVID-19 and Influenza. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration without regard to protected characteristics. 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 in accordance with relevant laws.