Remote DRG Clinical Audit Lead

Elevance Health; Mason (OH); Hybrid; USD 122,000 - 183,000; Full time

Job summary

Elevance Health seeks a DRG Clinical Auditor Principal to audit inpatient medical records and DRG-based claims using MS-DRG, APR-DRG and related methodologies across all lines of business. The role emphasizes autonomous work with high-quality audit output and potential to influence process improvements.

The candidate will validate coding accuracy, prepare detailed audit letters, and collaborate with management on criteria for identifying recoveries and opportunities, including complex DRG cases

Qualifications

• Extensive experience with ICD-9/10CM and DRG methodologies (MS-DRG, AP-DRG, APR-DRG).
• Certifications in RHIA, RHIT, CCS, CIC, CCDS or equivalent are required or preferred.
• At least 10 years in ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG across inpatient coding/audit.

Responsibilities

• Audit inpatient medical records and DRG coding for complex cases using APS-DRG, APR-DRG, AP-DRG, MS-DRG or TRICARE methods.
• Generate audit findings letters and validate accuracy against coding guidelines and ICD-10 references.
• Identify new claim types and opportunities for recoveries and process improvements.
• Collaborate with management to refine selection criteria and improve audit outcomes.
• Perform secondary audits on reviews conducted by other coders.

Skills

ICD-10 coding

Auditing

Claims analysis

Education

AA/AS or 15 years claims exp

RHIA/RHIT/CCS/CIC/CCDS

Job description

Elevance Health seeks a DRG Clinical Auditor Principal to audit inpatient medical records and DRG-based claims using MS-DRG, APR-DRG and related methodologies across all lines of business. The role emphasizes autonomous work with high-quality audit output and potential to influence process improvements.

The candidate will validate coding accuracy, prepare detailed audit letters, and collaborate with management on criteria for identifying recoveries and opportunities, including complex DRG cases