Remote DRG Clinical Validation Lead

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

Job summary

Elevance Health is seeking a DRG Clinical Validation Lead to ensure medically appropriate, high quality, cost effective care by assessing medical necessity across inpatient and outpatient services, using medical policy and industry standards.

This role involves pre-certification reviews, collaboration with medical directors, discharge planning, and leading cross-functional initiatives. Must have RN license and 7+ years acute care and managed care experience.

Qualifications

• Requires AS in nursing and at least 7 years of acute care clinical experience, with prior managed care exposure.
• Current, unrestricted RN license in applicable states is required.
• Preferred certifications: RHIT, RHIA, CCDS, CDIP, CPC or CCS/CIC are advantageous.

Responsibilities

• Conducts pre-certification, retrospective, out-of-network and appropriateness reviews to ensure compliance with criteria and policy.
• Ensures access to medically necessary, cost-effective care per contract.
• Collaborates with medical directors and providers to review care appropriateness and discharge planning.
• Leads cross-functional teams and process improvement initiatives as needed.

Skills

Acute care experience

RN license

Education

AS in nursing

Job description

Elevance Health is seeking a DRG Clinical Validation Lead to ensure medically appropriate, high quality, cost effective care by assessing medical necessity across inpatient and outpatient services, using medical policy and industry standards.

This role involves pre-certification reviews, collaboration with medical directors, discharge planning, and leading cross-functional initiatives. Must have RN license and 7+ years acute care and managed care experience.