Elevance Health
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and
Elevance Health, Las Vegas, Nevada, us, 89105
Diagnosis Related Group Clinical Validation Auditor - RN (CDI, MS-DRG, AP-DRG, APR-DRG)
Join to apply for the
Diagnosis Related Group Clinical Validation Auditor - RN
role at
Elevance Health .
Base Pay Range $81,852.00 / yr – $155,088.00 / yr.
Virtual Role This role enables associates to work virtually full‑time, with required in‑person training sessions. Training and onboarding are conducted face‑to‑face to ensure essential skill development.
Responsibilities
Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines, and objectivity in performing audit activities.
Draws on advanced ICD‑10 coding expertise, mastery of clinical guidelines, and industry knowledge to substantiate conclusions.
Utilizes audit tools, workflow systems and reference information to generate audit determinations and 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.
Minimum Requirements
Current, active, unrestricted Registered Nurse license in applicable state(s).
Minimum 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 equivalent education and experience.
Preferred Skills, Capabilities and Experiences
Certified or registered credentials such as RHIT, RHIA, CCDS, CDIP, CPC, CCS or CIC.
Experience with third‑party DRG coding and/or clinical validation audits or hospital clinical documentation improvement.
Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology.
Locations California, Colorado, District of Columbia (Washington, DC), Illinois, Maryland, Minnesota, Nevada, New York, Washington State.
Benefits and Compensation In addition to the base salary, Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution (subject to eligibility requirements). The offered salary is based on legal, non‑discriminatory factors and may vary based on location, experience, education, and skill level.
Equal Employment 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 applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Seniority Level Mid‑Senior level
Employment Type Full‑time
Job Function Management
Industries Business Consulting and Services
#J-18808-Ljbffr
Diagnosis Related Group Clinical Validation Auditor - RN
role at
Elevance Health .
Base Pay Range $81,852.00 / yr – $155,088.00 / yr.
Virtual Role This role enables associates to work virtually full‑time, with required in‑person training sessions. Training and onboarding are conducted face‑to‑face to ensure essential skill development.
Responsibilities
Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines, and objectivity in performing audit activities.
Draws on advanced ICD‑10 coding expertise, mastery of clinical guidelines, and industry knowledge to substantiate conclusions.
Utilizes audit tools, workflow systems and reference information to generate audit determinations and 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.
Minimum Requirements
Current, active, unrestricted Registered Nurse license in applicable state(s).
Minimum 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 equivalent education and experience.
Preferred Skills, Capabilities and Experiences
Certified or registered credentials such as RHIT, RHIA, CCDS, CDIP, CPC, CCS or CIC.
Experience with third‑party DRG coding and/or clinical validation audits or hospital clinical documentation improvement.
Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology.
Locations California, Colorado, District of Columbia (Washington, DC), Illinois, Maryland, Minnesota, Nevada, New York, Washington State.
Benefits and Compensation In addition to the base salary, Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution (subject to eligibility requirements). The offered salary is based on legal, non‑discriminatory factors and may vary based on location, experience, education, and skill level.
Equal Employment 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 applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Seniority Level Mid‑Senior level
Employment Type Full‑time
Job Function Management
Industries Business Consulting and Services
#J-18808-Ljbffr