Elevance Health
Position Title:
DRG Coding Auditor Job Description: The
DRG CODING AUDITOR
is responsible for auditing inpatient medical records and generating high-quality recoverable claims for the benefit of the company, for all lines of business, and its clients. Also responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding and DRG assignment accuracy. How you will make an impact: 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, clinical guidelines, and industry knowledge to substantiate conclusions. Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters. Maintains accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing). 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, and HACs. Suggests and develops high-quality, high-value concept and or process improvement and efficiency recommendations. Minimum Requirements: Requires at least one of the following: AA/AS or minimum of 5 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 and/or RHIT certification as a Registered Health Information Technician and/or CCS as a Certified Coding Specialist and/or CIC as a Certified Inpatient Coder. Requires 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG. Preferred Skills, Capabilities, and Experiences : BA/BS preferred. Experience with vendor-based DRG Coding/Clinical Validation Audit setting or hospital coding or quality assurance environment preferred. Broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria, and coding terminology preferred. Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred. 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 or condition protected by applicable federal, state, or local laws.
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DRG Coding Auditor Job Description: The
DRG CODING AUDITOR
is responsible for auditing inpatient medical records and generating high-quality recoverable claims for the benefit of the company, for all lines of business, and its clients. Also responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding and DRG assignment accuracy. How you will make an impact: 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, clinical guidelines, and industry knowledge to substantiate conclusions. Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters. Maintains accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing). 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, and HACs. Suggests and develops high-quality, high-value concept and or process improvement and efficiency recommendations. Minimum Requirements: Requires at least one of the following: AA/AS or minimum of 5 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 and/or RHIT certification as a Registered Health Information Technician and/or CCS as a Certified Coding Specialist and/or CIC as a Certified Inpatient Coder. Requires 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG. Preferred Skills, Capabilities, and Experiences : BA/BS preferred. Experience with vendor-based DRG Coding/Clinical Validation Audit setting or hospital coding or quality assurance environment preferred. Broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria, and coding terminology preferred. Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred. 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 or condition protected by applicable federal, state, or local laws.
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