Remote DRG Clinical Validation Lead

Elevance Health; Indianapolis (IN); Remote; USD 90,000 - 161,000; Full time

Job summary

Elevance Health is seeking a DRG Clinical Validation Lead to drive medically appropriate, high-quality care by evaluating inpatient and outpatient services against medical policy and benefits. This remote role requires strong clinical judgment and experience in managed care.

You will partner with medical directors, reviewers, and providers to ensure accurate claims payment, discharge planning, and adherence to accreditation standards while navigating complex clinical reviews across multiple

Qualifications

• Requires AS in nursing and at least 7 years of acute care clinical experience.
• Prior managed care experience required.
• Current unrestricted RN license in applicable state(s).

Responsibilities

• Conducts pre-certification and retrospective reviews to ensure medical policy compliance and eligibility.
• Assesses appropriateness of treatment settings and out-of-network care.
• Collaborates with providers to plan discharge and transition care.
• Leads cross-functional initiatives and supports accreditation efforts.
• Serves as departmental liaison on enterprise initiatives.

Skills

RN license

Acute care experience

Managed care experience

Clinical policy interpretation

Education

AS in nursing

Job description

Elevance Health is seeking a DRG Clinical Validation Lead to drive medically appropriate, high-quality care by evaluating inpatient and outpatient services against medical policy and benefits. This remote role requires strong clinical judgment and experience in managed care.

You will partner with medical directors, reviewers, and providers to ensure accurate claims payment, discharge planning, and adherence to accreditation standards while navigating complex clinical reviews across multiple