DRG Coding Auditor Principal

Position

DRG Coding Auditor Principal is responsible for auditing inpatient medical records on claims paid based on Diagnostic Related Group (DRG) methodology, including case rate and per diem. The role generates highly complex audit findings recoverable claims for the benefit of the company and its clients across all lines of business. The expert focuses on reviewing DRG coding via medical record and attending physician’s statement provided by acute care hospitals on paid DRG, especially on very complex coding cases paid using APS‑DRG, APR‑DRG, AP‑DRG, MS‑DRG or TRICARE methodology.

• Analyze and audit claims by integrating advanced medical chart coding principles from the Official Coding Guidelines, Coding Clinics, and ICD‑10 Alphabetic and Tabular Indices, as well as complex clinical guidelines.
• Apply advanced ICD‑10 coding expertise, clinical guidelines, and industry knowledge to substantiate sophisticated conclusions.
• Utilize audit tools, workflow systems, and reference information to make audit determinations and generate audit findings letters.
• Validate accuracy and quality standards set by audit management for claim identification and documentation purposes.
• Identify new claim types and potential recoveries, such as re‑admissions, Inpatient‑to‑Outpatient transitions, Hospital Acquired Conditions (HACs), Preventable Adverse Events (PAEs), or Never Events.
• Suggest and develop high‑quality concept and process improvement recommendations.
• Operate largely independently and autonomously with minimal oversight, providing high‑quality outputs understood by only advanced DRG Coding Auditors.
• Perform secondary audits on claims reviewed by other DRG coders for missed opportunities and identify gaps in foundational audit knowledge.
• Collaborate with management to improve selection criteria.

• At least 15 years of experience in claims auditing, quality assurance, or recovery auditing, or equivalent education.
• Certification: RHIA, RHIT, CCS, CIC, or CCDS.
• Minimum of 10 years experience working with ICD‑9/10‑CM, MS‑DRG, AP‑DRG, and APR‑DRG.

• BA/BS degree preferred.
• Experience in vendor‑based DRG coding/clinical validation audit, hospital coding, or a quality assurance environment.
• Broad, deep, and niche knowledge of medical claims billing/payment systems, payer reimbursement policies, billing validation criteria, and coding terminology.

The salary range for this position is $119,760 to $206,586. Locations include California, Illinois, Minnesota, and New Jersey.

Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, 401(k) contribution, and other benefits subject to eligibility requirements.

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, marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthj for assistance.