DRG Coding Auditor - MS-DRG and APR-DRG

Elevance Health; Chicago (IL); Hybrid; USD 93,000 - 160,000; Full time

Job summary

Elevance Health is seeking a DRG Coding Auditor to audit inpatient medical records and generate recoverable claims across lines of business, ensuring accurate DRG assignment with MS-DRG and APR-DRG methodologies.

You will apply ICD-10 guidelines and clinical documentation principles in medical record reviews, supporting high-quality recoveries and audit findings while collaborating with hospitals and internal teams. The role offers hybrid/remote work with required in-person training.

Qualifications

• Requires AA/AS or 5+ years in claims auditing or recovery auditing.
• ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG experience required.
• Certifications RHIA, RHIT, CCS, CIC or CCDS preferred.

Responsibilities

• Analyze and audit inpatient claims by integrating coding principles and clinical guidelines.
• Draw on ICD-10 coding expertise to substantiate conclusions.
• Utilize audit tools and workflow systems to generate audit findings letters.
• Maintain accuracy and quality standards for auditing concepts and documentation.
• Identify new claim types and opportunities for recoveries and improvements.

Skills

ICD-10 coding

Medical record auditing

Clinical documentation review

Education

AA/AS or equivalent

BA/BS preferred

Tools

Audit tools

DRG workflow systems

Job description

DRG Coding Auditor - MS-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. Alternate locations may be considered if candidates reside within a commuting distance from an office

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 Coding Auditor is responsible for auditing inpatient medical records and generating high quality recoverable claims for the benefit of the company, for all lines of business, and its clients. Also responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding and DRG assignment accuracy. Specializes in review of DRG coding via medical record and attending physician’s statement sent in by acute care hospitals on submitted DRG.

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, clinical guidelines, and industry knowledge to substantiate conclusions.

• Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters.

• Maintains accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing). Identifies new claim types by identifying potential claims outside of the concept where additional recoveries may be available, such as re-admissions, Inpatient to Outpatient, and HACs.

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

Minimum Requirements

• Requires at least one of the following: AA/AS or minimum of 5 years of experience in claims auditing, quality assurance, or recovery auditing.

• Requires at least one of the following certifications: RHIA certification as a Registered Health Information Administrator, RHIT certification as a Registered Health Information Technician, CCS as a Cert Coding Specialist, CIC as a Certified Inpatient Coder, or Certified Clinical Documentation Specialist (CCDS).

• Requires 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG.

Preferred Skills, Capabilities and Experiences

• BA/BS preferred.

• Experience with vendor based DRG Coding / Clinical Validation Audit setting or hospital coding or quality assurance environment preferred.

• Broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology preferred.

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $92,880 - $160,218

Locations: California; Illinois; Maryland; New York; Virginia

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, paid time off, stock, 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.

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.

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 are 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.

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.

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.

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 may contact [e-mail] for assistance.

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.