Registered Nurse - Diagnosis Related Group; DRG) Coding Auditor Principal – Carelon Int

Registered Nurse - Diagnosis Related Group Coding Auditor Principal – Carelon Payment Integrity

Location: Alternate locations may be considered. This position will work in a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.

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.

The DRG Coding Auditor Principal is responsible for auditing inpatient medical records on claims paid based on Diagnostic Relation Group (DRG) methodology, including case rate and per diem, generating highly complex audit findings recoverable claims for the benefit of the Company, for all lines of business, and its clients. Specializes in review of DRG coding via medical records and attending physician’s statements provided by acute care hospitals on paid DRG, especially on very complex coding cases that are paid using APS-DRG, APR-DRG, AP-DRG, MS-DRG or TRICARE methodology and findings may be so complex and advanced that disputes or appeals may only be reviewed by other DRG Coding Audit Principals (or Executives).

How you will make an impact:

• Analyzes and audits claims by integrating advanced or convoluted medical chart coding principles (found in the Official Coding Guidelines, Coding Clinics, and the ICD-10 Alphabetic and Tabular Indices), complex clinical guidelines, and maintaining objectivity in the performance of medical audit activities.
• Draws on extremely advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate sophisticated conclusions.
• Utilizes audit tools auditing 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) on lower-level auditors. Identifies new claim types by identifying potential claims outside of the concept where additional recoveries may be available, such as re-admissions, Inpatient to Outpatient, Hospital Acquired Conditions (HACs), Preventable Adverse Events (PAEs), or Never Events.
• Suggests and develops high-quality, high-value concept and or process improvement and efficiency recommendations.
• Operates largely independently and autonomously with little oversight due to extremely high-quality output and audit results that only the most advanced and experienced DRG Coding Auditors would understand.
• Performs secondary audits on claims that have been reviewed by other DRG Coders for missed opportunities and identifies gaps in foundational audit knowledge.
• Collaborates with management to improve selection criteria.

Minimum Requirements:

• AA/AS or minimum of 15 years of experience in claims auditing, quality assurance, or recovery auditing.
• Requires at least one of the following certifications: RHIA certification as a Registered Health Information Administrator, RHIT certification as a Registered Health Information Technician, CCS as a Certified Coding Specialist, CIC as a Certified Inpatient Coder, or Certified Clinical Documentation Specialist (CCDS).
• Requires minimum of 10 years experience working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG.

Preferred Qualifications, Skills, and Experiences:

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