Diagnosis Related Group Clinical Validation Auditor

Elevance Health; Atlanta (GA); Remote; USD 110,000 - 140,000; Full time

Job summary

Elevance Health, Inc. is seeking a Diagnosis Related Group Clinical Validation Auditor to audit inpatient medical records and ensure DRG coding aligns with conditions billed and reimbursed.

This remote role emphasizes independent work with required in-person training sessions and strict adherence to travel/commuting policies. The auditor will leverage ICD-10 coding knowledge, clinical guidelines, and auditing systems to deliver precise determinations, high-quality findings, and opportunities for

Qualifications

• Requires AS/AA degree and a minimum of 8 years of experience in claims auditing, quality assurance, or clinical documentation improvement.
• Requires a minimum of 5 years of experience with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG; or equivalent background.
• Requires current, active, valid and unrestricted Registered Nurse license in applicable state(s).

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 HACs.
• Suggests and develops high quality, high value, concept and or process improvement and efficiency recommendations.

Skills

ICD-10 coding

Clinical guidelines

Education

AS/AA degree

Tools

Audit tools

Job description

Anticipated End Date

2026-11-30

Position Title

Diagnosis Related Group Clinical Validation Auditor

Job Description

Diagnosis Related Group Clinical Validation Auditor

Location

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The DRG 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.

How you will make an impact

• 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 an AS/AA degree and a minimum of 8 years of experience in claims auditing, quality assurance, or clinical documentation improvement. Requires 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, which would provide an equivalent background. Requires current, active, valid and unrestricted Registered Nurse license in applicable state(s).

Preferred Skills, Capabilities and Experiences

• One or more of the following certifications are preferred: 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 experience preferred.
• Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred.

Job Level

Non-Management Exempt

Job Family

MED > Licensed/Certified - Other

Please be advised that 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.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words - the job is posted until 3/13, not through 3/13.