Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)

Elevance Health; Richmond (VA); Remote; USD 80,000 - 100,000; Full time

Job summary

A leading healthcare company is seeking a Diagnosis Related Group Clinical Validation Auditor-RN to audit inpatient medical records. This virtual role requires significant experience in claims auditing and clinical documentation improvement. Responsibilities include ensuring billing accuracy and identifying documentation errors. The position offers flexibility but requires a current RN license and in-depth coding expertise.

Qualifications

• 10+ years in claims auditing or quality assurance.
• 5+ years experience with ICD-9/10CM and MS-DRG.
• Proven ability to analyze clinical documentation.

Responsibilities

• Audit medical records for billing accuracy.
• Provide detailed audit findings letters.
• Identify potential documentation errors.

Skills

ICD-10 coding expertise

Clinical documentation improvement

Claims auditing

Attention to detail

Education

Unrestricted Registered Nurse license

Job description

Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)

Virtual: 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 hybrid/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.

Work Shift: Monday - Friday 8AM -5PM (local time)

The Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG) 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 current, active, unrestricted Registered Nurse license in applicable state(s).

• Requires a minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement, and 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.

Preferred Skills, Capabilities and Experiences:

• One or more of the following certifications are preferred: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), 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.

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.