Elevance Health
DRG Coding Auditor Principal
Join to apply for the
DRG Coding Auditor Principal
role at
Elevance Health .
Base Pay Range $119,760.00/yr - $206,586.00/yr
Locations California; Illinois; Minnesota; New Jersey;
Role Overview The
DRG Coding Auditor Principal
is responsible for auditing inpatient medical records on claims paid based on Diagnostic Relation Group (DRG) methodology, including case rate and per diem. The role focuses on generating highly complex audit findings to recover claims for the benefit of the company and its clients, with emphasis on very complex coding cases paid using APS-DRG, APR-DRG, AP-DRG, MS-DRG or TRICARE methodology.
Responsibilities
Analyze and audit claims by integrating advanced medical chart coding principles from the Official Coding Guidelines, Coding Clinics, and the ICD-10 Alphabetic and Tabular Indices.
Draw on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate sophisticated conclusions.
Utilize audit tools and workflow systems to make audit determinations and generate audit findings letters.
Validate accuracy and quality standards as set by audit management for the auditing concept, claim identification, and documentation purposes.
Identify new claim types and potential recoveries, such as re‑admissions, inpatient-to‑outpatient transitions, Hospital Acquired Conditions (HACs), Preventable Adverse Events (PAEs), and Never Events.
Suggest and develop high‑quality, high‑value concept and process improvement recommendations.
Operate largely independently and autonomously with minimal oversight, delivering high‑quality output and audit results.
Perform secondary audits on claims reviewed by other DRG coders, identifying missed opportunities and gaps in foundational audit knowledge.
Collaborate with management to improve selection criteria.
Minimum Requirements
At least one of the following: AA/AS degree or a minimum of 15 years of experience in claims auditing, quality assurance, or recovery auditing.
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 Skills, Capabilities and Experiences
BA/BS degree preferred.
Experience in vendor‑based DRG coding/clinical validation audit settings or hospital coding/quality assurance environments.
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.
Seniority Level
Mid‑Senior level
Employment Type
Full‑time
Job Function
Accounting/Auditing and Finance
Industries
Accounting
Benefits Elevance Health offers a comprehensive benefits package, including incentive and recognition programs, equity stock purchase, 401(k) contribution, medical, dental, vision, short‑term and long‑term disability benefits, life insurance, wellness programs, and financial education resources. All benefits are subject to eligibility requirements.
Equal Employment Opportunity Statement 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 (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 in accordance with federal, state, and local laws, including the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
Agency Resume Policy Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
COVID‑19 and Flu Vaccination Policy The health of our associates and communities is a top priority. Candidates for certain patient/member‑facing roles are required to become vaccinated against COVID‑19 and influenza. If you are not vaccinated, your offer may be rescinded unless you provide an acceptable explanation. Elevance Health will follow all relevant federal, state, and local laws.
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DRG Coding Auditor Principal
role at
Elevance Health .
Base Pay Range $119,760.00/yr - $206,586.00/yr
Locations California; Illinois; Minnesota; New Jersey;
Role Overview The
DRG Coding Auditor Principal
is responsible for auditing inpatient medical records on claims paid based on Diagnostic Relation Group (DRG) methodology, including case rate and per diem. The role focuses on generating highly complex audit findings to recover claims for the benefit of the company and its clients, with emphasis on very complex coding cases paid using APS-DRG, APR-DRG, AP-DRG, MS-DRG or TRICARE methodology.
Responsibilities
Analyze and audit claims by integrating advanced medical chart coding principles from the Official Coding Guidelines, Coding Clinics, and the ICD-10 Alphabetic and Tabular Indices.
Draw on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate sophisticated conclusions.
Utilize audit tools and workflow systems to make audit determinations and generate audit findings letters.
Validate accuracy and quality standards as set by audit management for the auditing concept, claim identification, and documentation purposes.
Identify new claim types and potential recoveries, such as re‑admissions, inpatient-to‑outpatient transitions, Hospital Acquired Conditions (HACs), Preventable Adverse Events (PAEs), and Never Events.
Suggest and develop high‑quality, high‑value concept and process improvement recommendations.
Operate largely independently and autonomously with minimal oversight, delivering high‑quality output and audit results.
Perform secondary audits on claims reviewed by other DRG coders, identifying missed opportunities and gaps in foundational audit knowledge.
Collaborate with management to improve selection criteria.
Minimum Requirements
At least one of the following: AA/AS degree or a minimum of 15 years of experience in claims auditing, quality assurance, or recovery auditing.
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 Skills, Capabilities and Experiences
BA/BS degree preferred.
Experience in vendor‑based DRG coding/clinical validation audit settings or hospital coding/quality assurance environments.
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.
Seniority Level
Mid‑Senior level
Employment Type
Full‑time
Job Function
Accounting/Auditing and Finance
Industries
Accounting
Benefits Elevance Health offers a comprehensive benefits package, including incentive and recognition programs, equity stock purchase, 401(k) contribution, medical, dental, vision, short‑term and long‑term disability benefits, life insurance, wellness programs, and financial education resources. All benefits are subject to eligibility requirements.
Equal Employment Opportunity Statement 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 (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 in accordance with federal, state, and local laws, including the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
Agency Resume Policy Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
COVID‑19 and Flu Vaccination Policy The health of our associates and communities is a top priority. Candidates for certain patient/member‑facing roles are required to become vaccinated against COVID‑19 and influenza. If you are not vaccinated, your offer may be rescinded unless you provide an acceptable explanation. Elevance Health will follow all relevant federal, state, and local laws.
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