Clinical Validation Auditor – RN, CDI, MS-DRG, AP-DRG, APR-DRG

🔥 7 minutes ago

🏄 California, Colorado, +6 more states – Remote

🏄 California – Remote ⛰️ Colorado – Remote 🌽 Illinois – Remote 🎰 Nevada – Remote 🗽 New York – Remote 🦀 Maryland – Remote ❄️ Minnesota – Remote ☕ Washington – Remote

💵 $86.6k - $155.8k / year

⏰ Full Time

🟠 Senior

🔴 Lead

🔎 Auditor

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Elevance Health

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

🤝 B2B

Healthcare • Healthcare Insurance • B2B

Elevance Health is transforming from a traditional health benefits organization into a lifetime trusted health partner, driven by a bold purpose to improve the health of humanity. With nearly 100,000 associates, they serve over 118 million people and utilize an integrated whole health approach supported by industry-leading capabilities and a digital health platform. Their mission includes redefining health, reimagining the health system, and strengthening communities.

📋 Description

• Audit inpatient medical records to ensure clinical documentation supports billed and reimbursed conditions and DRGs • Review Diagnosis Related Group (DRG) paid claims • Analyze and audit claims using medical chart coding principles, clinical guidelines, and objective medical audit practices • Apply advanced ICD-10 coding expertise and clinical guidelines to substantiate audit conclusions • Use audit tools, workflow systems, and reference information to generate audit determinations and detailed audit findings letters • Maintain accuracy and quality standards established by audit management • Identify documentation and coding errors and aberrant patterns, including inappropriate readmissions, inpatient admission status, and Hospital-Acquired Conditions • Suggest and develop concept, process improvement, and efficiency recommendations

🎯 Requirements

• Current, active, unrestricted Registered Nurse license in applicable state(s) required • Minimum 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement • Minimum 5 years of experience working with ICD-9/10-CM, MS-DRG, AP-DRG, and APR-DRG • Education and experience combination providing an equivalent background may qualify • RHIT, RHIA, CCDS, CDIP, CPC, CCS, or CIC certification preferred • Experience with third-party DRG coding and/or clinical validation audits or hospital clinical documentation improvement preferred • Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred

🏖️ Benefits

• Comprehensive benefits package • Incentive and recognition programs • Equity stock purchase • 401k contribution • Merit increases • Paid holidays • Paid Time Off • Incentive bonus programs • Medical benefits • Dental benefits • Vision benefits • Short-term disability benefits • Long-term disability benefits • 401(k) with match • Stock purchase plan • Life insurance • Wellness programs • Financial education resources