Elevance Health
Job Description
DRG CODING AUDITOR 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.
Please note that per our policy on hybrid / virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
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 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. Specializes in review of DRG coding via medical record and attending physician’s statement sent in by acute care hospitals on submitted DRG.
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, RHIT, CCS, or CIC.
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 on negotiation preferred.
Salary range for this position is $95,172 to $149,556.
Locations: Colorado; Illinois; Maryland; Minnesota; Nevada
In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401(k) contribution (all benefits subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non‑discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
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. Applicants who require accommodation to participate in the job application process may contact the company for assistance.
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DRG CODING AUDITOR 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.
Please note that per our policy on hybrid / virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
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 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. Specializes in review of DRG coding via medical record and attending physician’s statement sent in by acute care hospitals on submitted DRG.
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, RHIT, CCS, or CIC.
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 on negotiation preferred.
Salary range for this position is $95,172 to $149,556.
Locations: Colorado; Illinois; Maryland; Minnesota; Nevada
In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401(k) contribution (all benefits subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non‑discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
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. Applicants who require accommodation to participate in the job application process may contact the company for assistance.
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