Remote DRG Clinical Validation Auditor (ICD-10 Expert)

The Elevance Health Companies, Inc.; Cincinnati (OH); Remote; USD 95,000 - 150,000; Full time

Job summary

Elevance Health is seeking a Diagnosis Related Group Clinical Validation Auditor to join our team in a remote-capable role with required in-person training sessions. The position emphasizes expert ICD-10 coding, clinical guidelines, and audit discipline to ensure accurate DRG determinations and documentation quality.

Ideal candidates will hold an RN license and have substantial experience in claims auditing and clinical documentation improvement, with familiarity in DRG concepts and hospital

Qualifications

• Requires an 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 working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG; or any combination of education and experience providing 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 Hospital-Acquired Conditions (HACs).
• Suggests and develops high quality, high value, concept and or process improvement and efficiency recommendations.

Education

AS/AA degree

Tools

Audit tools

Auditing workflow systems

Job description

Elevance Health is seeking a Diagnosis Related Group Clinical Validation Auditor to join our team in a remote-capable role with required in-person training sessions. The position emphasizes expert ICD-10 coding, clinical guidelines, and audit discipline to ensure accurate DRG determinations and documentation quality.

Ideal candidates will hold an RN license and have substantial experience in claims auditing and clinical documentation improvement, with familiarity in DRG concepts and hospital