Remote DRG Clinical Validation Auditor

Elevance Health, Inc.; Atlanta (GA); Remote; USD 110,000 - 140,000; Full time

Job summary

Elevance Health, Inc. is seeking a Diagnosis Related Group Clinical Validation Auditor to audit inpatient medical records and ensure DRG coding aligns with conditions billed and reimbursed.

This remote role emphasizes independent work with required in-person training sessions and strict adherence to travel/commuting policies. The auditor will leverage ICD-10 coding knowledge, clinical guidelines, and auditing systems to deliver precise determinations, high-quality findings, and opportunities for

Qualifications

• Requires AS/AA degree and a minimum of 8 years of experience in claims auditing, quality assurance, or clinical documentation improvement.
• Requires a minimum of 5 years of experience with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG; or equivalent background.
• Requires current, active, valid and unrestricted Registered Nurse license in applicable state(s).

Responsibilities

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

Skills

ICD-10 coding

Clinical guidelines

Education

AS/AA degree

Tools

Audit tools

Job description

Elevance Health, Inc. is seeking a Diagnosis Related Group Clinical Validation Auditor to audit inpatient medical records and ensure DRG coding aligns with conditions billed and reimbursed.

This remote role emphasizes independent work with required in-person training sessions and strict adherence to travel/commuting policies. The auditor will leverage ICD-10 coding knowledge, clinical guidelines, and auditing systems to deliver precise determinations, high-quality findings, and opportunities for