DRG Coding Auditor Principal

DRG Coding Auditor Principal

Virtual: This role enables associates to work virtually full‑time, with the exception of required in‑person training sessions, providing maximum flexibility and autonomy. All candidates must be within a reasonable commuting distance from the posting location(s) unless an accommodation is required by law.

• Analyzes and audits claims by integrating advanced coding principles from the Official Coding Guidelines, Coding Clinics, and the ICD‑10 Alphabetic and Tabular Indices, complex clinical guidelines, and maintains objectivity in all audit activities.
• Draws on advanced ICD‑10 coding expertise, clinical guidelines, and industry knowledge to substantiate sophisticated conclusions.
• Utilizes audit tools, workflow systems, and reference information to make audit determinations and generate audit findings letters.
• Validates accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing) for lower‑level auditors.
• Identifies new claim types and potential recoveries, such as re‑admissions, inpatient‑to‑outpatient transfers, hospital‑acquired conditions (HACs), preventable adverse events (PAEs), and never events.
• Suggests and develops high‑quality, high‑value conceptual and process improvements and efficiency recommendations.
• Operates largely independently and autonomously with little oversight, achieving extremely high‑quality output and audit results that only the most experienced DRG Coding Auditors understand.
• Performs secondary audits on claims reviewed by other DRG Coders to uncover missed opportunities and identify gaps in foundational audit knowledge.
• Collaborates with management to improve selection criteria.

• At least 15 years of experience in claims auditing, quality assurance, or recovery auditing, or an AA/AS degree.
• At least one of the following certifications: RHIA, RHIT, CCS, CIC, or CCDS.
• Minimum of 10 years of experience with ICD‑9/10CM, MS‑DRG, AP‑DRG, and APR‑DRG.

• BA/BS degree preferred.
• Experience with vendor‑based DRG Coding/Clinical Validation Audit setting or hospital coding/quality assurance environment preferred.
• Broad, deep, and niche knowledge of medical claims billing/payment systems, payer reimbursement policies, billing validation criteria, and coding terminology strongly preferred.

Salary range for this position: $119,760 – $206,586.

Locations:
California;
Illinois;
Minnesota;
New Jersey.

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 protected by federal, state, or local laws. Applicants who require accommodation may contact elevancehealthj for assistance.