Elevance Health
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and
Elevance Health, Denver, Colorado, United States, 80285
Overview
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG) at Elevance Health. Virtual:
This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential onboarding and skill development. Note: per policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location will not be considered for employment unless an accommodation is granted as required by law.
Responsibilities
Audits inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed; specializes in review of DRG paid claims.
Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines, and objectivity in 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 (e.g., inappropriate billing for readmissions, inpatient admission status, Hospital-Acquired Conditions).
Suggests and develops high quality, high value concepts and/or process improvement and efficiency recommendations.
Minimum Requirements
Current, active, unrestricted Registered Nurse license in applicable state(s).
Minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement, and a minimum of 5 years of experience with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG; or any combination of education and experience providing an equivalent background.
Preferred Skills, Capabilities And Experiences
One or more of the following certifications are preferred: RHIT, RHIA, CCDS, CDIP, CPC or inpatient coding credentials 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.
Salary and Location For candidates working in person or virtually in the location(s) below, the salary range for this position is
$81,852 to $155,088 .
Locations: California; Colorado; District of Columbia (Washington, DC); Illinois; Maryland; Minnesota; Nevada; New York; Washington State.
About Elevance Health and Equal Opportunity Elevance Health is a health company dedicated to improving lives and communities. We are a Fortune 25 company committed to equal pay opportunities and an inclusive work environment. Elevance Health is an Equal Employment Opportunity employer; applicants will be considered without regard to age, citizenship status, color, creed, disability, ethnicity, gender identity or expression, marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other status protected by law.
We also provide accommodations for applicants who require assistance during the job application process. Qualified applicants with arrest or conviction records will be considered in accordance with applicable laws.
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Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG) at Elevance Health. Virtual:
This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential onboarding and skill development. Note: per policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location will not be considered for employment unless an accommodation is granted as required by law.
Responsibilities
Audits inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed; specializes in review of DRG paid claims.
Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines, and objectivity in 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 (e.g., inappropriate billing for readmissions, inpatient admission status, Hospital-Acquired Conditions).
Suggests and develops high quality, high value concepts and/or process improvement and efficiency recommendations.
Minimum Requirements
Current, active, unrestricted Registered Nurse license in applicable state(s).
Minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement, and a minimum of 5 years of experience with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG; or any combination of education and experience providing an equivalent background.
Preferred Skills, Capabilities And Experiences
One or more of the following certifications are preferred: RHIT, RHIA, CCDS, CDIP, CPC or inpatient coding credentials 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.
Salary and Location For candidates working in person or virtually in the location(s) below, the salary range for this position is
$81,852 to $155,088 .
Locations: California; Colorado; District of Columbia (Washington, DC); Illinois; Maryland; Minnesota; Nevada; New York; Washington State.
About Elevance Health and Equal Opportunity Elevance Health is a health company dedicated to improving lives and communities. We are a Fortune 25 company committed to equal pay opportunities and an inclusive work environment. Elevance Health is an Equal Employment Opportunity employer; applicants will be considered without regard to age, citizenship status, color, creed, disability, ethnicity, gender identity or expression, marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other status protected by law.
We also provide accommodations for applicants who require assistance during the job application process. Qualified applicants with arrest or conviction records will be considered in accordance with applicable laws.
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