DRG Clinical Validation Lead

Elevance Health; Indianapolis (IN); Remote; USD 90,000 - 161,000; Full time

Job summary

Elevance Health is seeking a DRG Clinical Validation Lead to drive medically appropriate, high-quality care by evaluating inpatient and outpatient services against medical policy and benefits. This remote role requires strong clinical judgment and experience in managed care.

You will partner with medical directors, reviewers, and providers to ensure accurate claims payment, discharge planning, and adherence to accreditation standards while navigating complex clinical reviews across multiple

Qualifications

• Requires AS in nursing and at least 7 years of acute care clinical experience.
• Prior managed care experience required.
• Current unrestricted RN license in applicable state(s).

Responsibilities

• Conducts pre-certification and retrospective reviews to ensure medical policy compliance and eligibility.
• Assesses appropriateness of treatment settings and out-of-network care.
• Collaborates with providers to plan discharge and transition care.
• Leads cross-functional initiatives and supports accreditation efforts.
• Serves as departmental liaison on enterprise initiatives.

Skills

RN license

Acute care experience

Managed care experience

Clinical policy interpretation

Education

AS in nursing

Job description

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. The DRG Clinical Validation Lead ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.

How You Will Make An Impact

• Conducts pre-certification, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.
• Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
• Collaborates with providers to assess member's needs for early identification of and proactive planning for discharge planning.
• Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
• Serves as the team lead and responds to the most complex medical issues.
• Ensures consistency in benefit application. May lead cross-functional teams, projects, initiatives, process improvement activities, and requires previous managed care experience.
• May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives.

Minimum Requirements

• Requires AS in nursing and minimum of 7 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Prior managed care experience required. Current unrestricted RN license in applicable state(s) required.

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.
• Lead experience preferred.

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $89,520 to $161,136

Locations: California, Illinois, Maryland, Minnesota, Nevada, New York, Washington State

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

• The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.