Elevance Health
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and
Elevance Health, Port Reading, New Jersey, us, 07064
Overview
The Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG) role focuses on auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed. Base pay range $81,852.00/yr - $155,088.00/yr 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 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.
The Diagnosis Related Group Clinical Validation Auditor is responsible for auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims.
Responsibilities
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, 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 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
Requires current, active, unrestricted Registered Nurse license in applicable state(s).
Requires a minimum of 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 any combination of education and experience providing equivalent background.
Preferred Skills, Capabilities And Experiences
One or more of the following certifications are preferred: RHIT, RHIA, CCDS, CDIP, CPC or inpatient coding credential such as CCS or CIC.
Experience with third party DRG Coding and/or clinical validation audits or hospital CDI experience preferred.
Broad knowledge of CDI guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred.
Locations Locations: California; Colorado; District of Columbia (Washington, DC); Illinois; New Jersey; Maryland; Minnesota; Nevada; New York; Washington State
For compensation, Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contributions (eligibility applies). The salary range is $81,852 to $155,088 and may vary by geographic location, work experience, education, and skill level. Elevance Health is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender identity or expression, marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status protected by applicable laws. Applicants needing accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. The health of our associates and communities is a top priority. Some patient/member-facing roles may require vaccination against COVID-19 and Influenza; offers may be rescinded if vaccination is not provided unless an acceptable exemption is granted. This description is not intended to be exhaustive. Other duties reasonably related to the position may be assigned by management.
#J-18808-Ljbffr
The Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG) role focuses on auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed. Base pay range $81,852.00/yr - $155,088.00/yr 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 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.
The Diagnosis Related Group Clinical Validation Auditor is responsible for auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims.
Responsibilities
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, 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 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
Requires current, active, unrestricted Registered Nurse license in applicable state(s).
Requires a minimum of 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 any combination of education and experience providing equivalent background.
Preferred Skills, Capabilities And Experiences
One or more of the following certifications are preferred: RHIT, RHIA, CCDS, CDIP, CPC or inpatient coding credential such as CCS or CIC.
Experience with third party DRG Coding and/or clinical validation audits or hospital CDI experience preferred.
Broad knowledge of CDI guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred.
Locations Locations: California; Colorado; District of Columbia (Washington, DC); Illinois; New Jersey; Maryland; Minnesota; Nevada; New York; Washington State
For compensation, Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contributions (eligibility applies). The salary range is $81,852 to $155,088 and may vary by geographic location, work experience, education, and skill level. Elevance Health is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender identity or expression, marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status protected by applicable laws. Applicants needing accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. The health of our associates and communities is a top priority. Some patient/member-facing roles may require vaccination against COVID-19 and Influenza; offers may be rescinded if vaccination is not provided unless an acceptable exemption is granted. This description is not intended to be exhaustive. Other duties reasonably related to the position may be assigned by management.
#J-18808-Ljbffr