Elevance Health
Registered Nurse - Diagnosis Related Group (DRG) Coding Auditor Principal - Care
Elevance Health, Des Moines, Iowa, United States, 50319
Registered Nurse - Diagnosis Related Group (DRG) Coding Auditor Principal - Carelon Payment Integrity
Anticipated End Date: 2025-04-21
Overview 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.
Location Alternate locations may be considered. This position will work in a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint.
Responsibilities
Analyze and audit claims by integrating advanced or convoluted medical chart coding principles (found in the Official Coding Guidelines, Coding Clinics, and the ICD‑10 Alphabetic and Tabular Indices), complex clinical guidelines, and maintaining objectivity in the performance of medical audit activities.
Draw on extremely advanced ICD‑10 coding expertise, clinical guidelines, and industry knowledge to substantiate sophisticated conclusions.
Utilize audit tools, auditing workflow systems and reference information to make audit determinations and generate audit findings letters.
Validate accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing) on lower‑level auditors. Identify new claim types by identifying potential claims outside of the concept where additional recoveries may be available, such as re‑admissions, Inpatient to Outpatient, Hospital Acquired Conditions (HACs), Preventable Adverse Events (PAEs), or Never Events.
Suggest and develop high‑quality, high‑value concept and or process improvement and efficiency recommendations.
Operate largely independently and autonomously with little oversight due to extremely high‑quality output and audit results that only the most advanced and experienced DRG Coding Auditors would understand.
Perform secondary audits on claims that have been reviewed by other DRG Coders for missed opportunities and identify gaps in foundational audit knowledge.
Collaborate with management to improve selection criteria.
Qualifications
AA/AS or minimum of 15 years of experience in claims auditing, quality assurance, or recovery auditing.
Requires at least one of the following certifications: RHIA, RHIT, CCS, CIC, or CCDS.
Minimum of 10 years experience working with ICD‑9/10CM, MS‑DRG, AP‑DRG, and APR‑DRG.
Preferred Qualifications, Skills, and Experiences
BA/BS preferred.
Experience with vendor‑based DRG Coding / Clinical Validation Audit setting or hospital coding or quality assurance environment preferred.
Broad, deep, and niche knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria, and coding terminology strongly preferred.
Salary For candidates working in person or remotely in the below location(s), the salary* range for this specific position is $113,772 to $215,568.
Locations California; Colorado; District of Columbia (Washington, DC); Illinois; Maryland, Minnesota, Nevada; New York; Washington State
Benefits In addition to your 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). \ Position Details Job Level: Non‑Management Exempt
Workshift: 1st Shift (United States of America)
Job Family: MED > Licensed/Certified - Other
EEO Statement 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 elevancehealthjobssupport@elevancehealth.com for assistance.
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Overview 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.
Location Alternate locations may be considered. This position will work in a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint.
Responsibilities
Analyze and audit claims by integrating advanced or convoluted medical chart coding principles (found in the Official Coding Guidelines, Coding Clinics, and the ICD‑10 Alphabetic and Tabular Indices), complex clinical guidelines, and maintaining objectivity in the performance of medical audit activities.
Draw on extremely advanced ICD‑10 coding expertise, clinical guidelines, and industry knowledge to substantiate sophisticated conclusions.
Utilize audit tools, auditing workflow systems and reference information to make audit determinations and generate audit findings letters.
Validate accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing) on lower‑level auditors. Identify new claim types by identifying potential claims outside of the concept where additional recoveries may be available, such as re‑admissions, Inpatient to Outpatient, Hospital Acquired Conditions (HACs), Preventable Adverse Events (PAEs), or Never Events.
Suggest and develop high‑quality, high‑value concept and or process improvement and efficiency recommendations.
Operate largely independently and autonomously with little oversight due to extremely high‑quality output and audit results that only the most advanced and experienced DRG Coding Auditors would understand.
Perform secondary audits on claims that have been reviewed by other DRG Coders for missed opportunities and identify gaps in foundational audit knowledge.
Collaborate with management to improve selection criteria.
Qualifications
AA/AS or minimum of 15 years of experience in claims auditing, quality assurance, or recovery auditing.
Requires at least one of the following certifications: RHIA, RHIT, CCS, CIC, or CCDS.
Minimum of 10 years experience working with ICD‑9/10CM, MS‑DRG, AP‑DRG, and APR‑DRG.
Preferred Qualifications, Skills, and Experiences
BA/BS preferred.
Experience with vendor‑based DRG Coding / Clinical Validation Audit setting or hospital coding or quality assurance environment preferred.
Broad, deep, and niche knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria, and coding terminology strongly preferred.
Salary For candidates working in person or remotely in the below location(s), the salary* range for this specific position is $113,772 to $215,568.
Locations California; Colorado; District of Columbia (Washington, DC); Illinois; Maryland, Minnesota, Nevada; New York; Washington State
Benefits In addition to your 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). \ Position Details Job Level: Non‑Management Exempt
Workshift: 1st Shift (United States of America)
Job Family: MED > Licensed/Certified - Other
EEO Statement 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 elevancehealthjobssupport@elevancehealth.com for assistance.
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