Elevance Health
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and
Elevance Health, Tampa, Florida, us, 33646
Diagnosis Related Group Clinical Validation Auditor‑RN (CDI, MS‑DRG, AP‑DRG and APR‑DRG)
Title:
Diagnosis Related Group Clinical Validation Auditor‑RN (CDI, MS‑DRG, AP‑DRG and APR‑DRG)
Base pay range:
$81,852.00/yr – $155,088.00/yr
Location:
California, Colorado, District of Columbia (Washington, DC), Illinois, Maryland, Minnesota, Nevada, New York, Washington State
Virtual:
This role enables associates to work virtually full‑time, with required in‑person training sessions. Candidates must be within a reasonable commuting distance from the posting location unless an accommodation is provided.
Responsibilities
Analyze and audit inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed.
Draw on advanced ICD‑10 coding expertise, mastery of clinical guidelines, and industry knowledge to substantiate conclusions.
Utilize audit tools, workflow systems, and reference information to generate audit determinations and formulate detailed audit findings letters.
Maintain accuracy and quality standards as established by audit management.
Identify potential documentation and coding errors by recognizing aberrant coding patterns such as inappropriate billing for readmissions, admission status, and Hospital‑Acquired Conditions (HACs).
Suggest and develop high‑quality, high‑value concepts and process improvement recommendations.
Minimum Requirements
Current, active, unrestricted Registered Nurse license in applicable state(s).
Minimum of 10 years experience in claims auditing, quality assurance, or clinical documentation improvement, and a minimum of 5 years experience working with ICD‑9/10CM, MS‑DRG, AP‑DRG, and APR‑DRG (or equivalent background).
Preferred Skills, Capabilities, and Experiences
Preferred certifications: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC), or inpatient coding credential such as 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.
Equal Employment Opportunity 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. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
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Diagnosis Related Group Clinical Validation Auditor‑RN (CDI, MS‑DRG, AP‑DRG and APR‑DRG)
Base pay range:
$81,852.00/yr – $155,088.00/yr
Location:
California, Colorado, District of Columbia (Washington, DC), Illinois, Maryland, Minnesota, Nevada, New York, Washington State
Virtual:
This role enables associates to work virtually full‑time, with required in‑person training sessions. Candidates must be within a reasonable commuting distance from the posting location unless an accommodation is provided.
Responsibilities
Analyze and audit inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed.
Draw on advanced ICD‑10 coding expertise, mastery of clinical guidelines, and industry knowledge to substantiate conclusions.
Utilize audit tools, workflow systems, and reference information to generate audit determinations and formulate detailed audit findings letters.
Maintain accuracy and quality standards as established by audit management.
Identify potential documentation and coding errors by recognizing aberrant coding patterns such as inappropriate billing for readmissions, admission status, and Hospital‑Acquired Conditions (HACs).
Suggest and develop high‑quality, high‑value concepts and process improvement recommendations.
Minimum Requirements
Current, active, unrestricted Registered Nurse license in applicable state(s).
Minimum of 10 years experience in claims auditing, quality assurance, or clinical documentation improvement, and a minimum of 5 years experience working with ICD‑9/10CM, MS‑DRG, AP‑DRG, and APR‑DRG (or equivalent background).
Preferred Skills, Capabilities, and Experiences
Preferred certifications: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC), or inpatient coding credential such as 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.
Equal Employment Opportunity 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. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
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