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

🕒 September 18

🏄 California, Florida, +7 more states – Remote

🏄 California – Remote 🐊 Florida – Remote 🌽 Illinois – Remote 🎰 Nevada – Remote 🗽 New York – Remote 🌲 North Carolina – Remote ❄️ Minnesota – Remote 🤠 Texas – Remote ☕ Washington – Remote

💵 $86.6k - $155.8k / year

⏰ Full Time

🟠 Senior

🔴 Lead

🔎 Auditor

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 18%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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 objectivity • Apply advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate 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 potential documentation and coding errors, including inappropriate readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs) • Suggest and develop high-quality, high-value concept and/or process improvement and efficiency recommendations

🎯 Requirements

• Current, active, unrestricted Registered Nurse license in applicable state(s) • Minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement • Minimum of 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG; or an equivalent combination of education and experience • 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 • Candidates must reside within a reasonable commuting distance from the posting location(s), unless an accommodation is granted • Candidates in certain patient/member-facing roles must be vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided

🏖️ Benefits

• Incentive and recognition programs • Equity stock purchase • 401(k) contribution and match • Merit increases • Paid holidays • Paid Time Off • Incentive bonus programs • Medical, dental, and vision benefits • Short- and long-term disability benefits • Stock purchase plan • Life insurance • Wellness programs • Financial education resources • Required in-person training sessions for virtual associates • Professional and personal growth opportunities