Patient Safety DRG Clinical Validation Auditor

Elevance Health (Anthem); Indianapolis (IN); Remote; USD 87,000 - 130,000; Full time

Job summary

Elevance Health is seeking a Patient Safety DRG Clinical Validation Auditor to audit inpatient records for proper DRG billing. The role emphasizes advanced ICD-10 coding, clinical guidelines, and objective audit practices, with remote work options and in-person training sessions as needed.

Applicants should have a current RN license, 10+ years in related audits, and 5+ years with ICD-9/10CM and DRGs (MS/AP/APR-DRG).

Qualifications

• Active RN license in applicable state(s).
• 10+ years of claims auditing, quality assurance, or clinical documentation improvement experience.
• 5+ years working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG (or equivalent).

Responsibilities

• Audit inpatient medical records to ensure documentation supports DRGs billed and reimbursed.
• Apply ICD-10 coding principles and clinical guidelines to audit conclusions.
• Use audit tools and workflow systems to generate determinations and detailed findings letters.
• Identify documentation and coding errors (e.g., readmissions, inpatient status, HACs).
• Propose high-quality process improvements to enhance efficiency.

Skills

RN license

ICD-10 coding

DRG coding (MS-DRG/AP-DRG/APR-DRG)

Clinical audit experience

Job description

Job Description:

Location: This role enables associates to work virtually full-time, except for 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 accommodation is granted as required by law.

The Patient Safety 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'll make a difference:

• 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, qualifications 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.

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $86,560 to $129,840

Locations: Minnesota; Cleveland, Ohio and Columbus, Ohio

In additional 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.

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 t