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

Overview

Anticipated End Date:

Position Title: Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)

Job Description: Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)

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

The Diagnosis Related Group 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.

Location/Attendance Policy: For candidates working in person or virtually in the below location(s), the salary range for this specific position is $81,852 to $155,088. Elevance Health operates a Hybrid Workforce Strategy; associates are typically required to work at an Elevance Health location at least once per week, and potentially several times per week unless specified as primarily virtual by the hiring manager.

Specific onsite requirements will be discussed during the hiring process.

• 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:
  Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC) 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.
• 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 located in the listed locations, the salary range for this role is $81,852 to $155,088.

Locations: California;
Colorado;
District of Columbia (Washington, DC), Illinois, New Jersey;
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 (all benefits are subject to eligibility requirements). The salary offered is based on several factors and may be modified in the future. Elevance Health is an Equal Employment Opportunity employer and practice of equal pay for equal work is observed in accordance with applicable laws.

Additional Notes: 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 requirements for time onsite will be discussed during the hiring process. The organization may require vaccination for COVID-19 and Influenza for certain patient/member-facing roles, in accordance with federal, state, and local laws.

Equal Opportunity 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 or condition protected by law. Applicants who…