Diagnosis Related Group Clinical Validation Auditor

Elevance Health, Inc.; Oregon; Hybrid; USD 90,000 - 130,000; Full time

Job summary

Elevance Health seeks a Diagnosis Related Group Clinical Validation Auditor to audit claims and validate DRG coding accuracy. The position is primarily remote with mandatory in-person training sessions to build competencies.

Ideal candidates hold an RN license, AS/AA degree, and extensive experience with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG. The role supports our hybrid work model and ongoing professional development.

Qualifications

• Requires AS/AA degree and 8+ years in claims auditing or clinical documentation improvement.
• Requires RN license active and unrestricted in applicable state(s).
• Experience with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG; or equivalent background.

Responsibilities

• Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines, and objectivity in audit activities.
• Draws on advanced ICD-10 coding expertise and clinical guidelines to substantiate conclusions.
• Uses audit tools and workflow systems to generate audit determinations and detailed findings letters.
• Maintains accuracy and quality standards established by audit management.
• Identifies documentation and coding errors by recognizing aberrant patterns such as inappropriate billing for readmissions and HACs.
• Suggests and develops high-quality, value-driven process improvements.

Skills

ICD-10 coding

Auditing

Clinical documentation

Healthcare regulations

Education

AS/AA degree

Tools

Audit tools

Chart review systems

Job description

Anticipated End Date: 2026-11-30

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.

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

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They’re how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k)+match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Hybrid Workforce Strategy

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

Vaccination Requirements

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Equal Employment Opportunity

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 should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. 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. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration .