Remote DRG Clinical Validation Auditor

Elevance Health, Inc.; Cincinnati (OH); Remote; USD 90,000 - 130,000; Full time

Job summary

Elevance Health is seeking a Diagnosis Related Group Clinical Validation Auditor to audit inpatient medical records, ensuring clinical documentation supports the conditions and DRGs billed and reimbursed. This role specializes in reviewing DRG paid claims and operates largely in a virtual capacity, with in-person training sessions required.

You will apply advanced ICD-10 coding, clinical guideline mastery, and auditing tools to generate determinations and comprehensive finding letters.

Qualifications

• Requires AS/AA degree and 8+ years in claims auditing or clinical documentation improvement.
• Requires 5+ years working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG.
• Requires current, active, valid and unrestricted RN license in applicable state(s).

Responsibilities

• Audits inpatient records to ensure documentation supports DRGs billed and reimbursed.
• Applies ICD-10 coding principles and clinical guidelines in audit activities.
• Generates audit determinations and writes detailed audit findings letters.
• Maintains accuracy and quality standards per audit management.
• Identifies potential documentation and coding errors by recognizing aberrant patterns.
• Suggests high-quality, high-value process improvement recommendations.

Skills

Audit experience

Clinical documentation improvement

ICD-10 coding expertise

DRG knowledge

Education

AS/AA degree

RN license (state(s))

Tools

ICD-9/10CM

MS-DRG

AP-DRG

APR-DRG

Job description

Elevance Health is seeking a Diagnosis Related Group Clinical Validation Auditor to audit inpatient medical records, ensuring clinical documentation supports the conditions and DRGs billed and reimbursed. This role specializes in reviewing DRG paid claims and operates largely in a virtual capacity, with in-person training sessions required.

You will apply advanced ICD-10 coding, clinical guideline mastery, and auditing tools to generate determinations and comprehensive finding letters.