Remote DRG Clinical Validation Lead

Elevance Health; United States; Hybrid; USD 90,000 - 161,000; Full time

Benefits offered by this job

Hybrid/virtual work

Job summary

Elevance Health seeks a DRG Clinical Validation Lead to assess medical necessity and care quality across inpatient and outpatient services. The role supports virtual work with required in-person onboarding and occasional training sessions.

The position emphasizes collaboration with medical directors, DRG coding, and clinical documentation improvement to ensure compliant, cost-effective care. Located in the United States.

Qualifications

• RN license required or eligible in applicable state.
• Minimum 7 years acute care clinical experience with managed care exposure.
• Strong knowledge of medical policy and coding guidelines.

Responsibilities

• Conduct pre-certifications, retrospective reviews and appropriate setting determinations to ensure compliance with medical policy and contracts.
• Collaborate with clinical reviewers and medical directors to ensure high-quality, cost-effective care across the continuum.
• Lead cross-functional projects and process improvements within managed care operations.
• Coordinate discharge planning and transitions, avoiding non-certifications where possible.

Skills

Clinical assessment

Leadership

Cross-functional collaboration

Healthcare compliance

Education

AS in nursing

Tools

DRG Coding

Medical policy interpretation

Job description

Elevance Health seeks a DRG Clinical Validation Lead to assess medical necessity and care quality across inpatient and outpatient services. The role supports virtual work with required in-person onboarding and occasional training sessions.

The position emphasizes collaboration with medical directors, DRG coding, and clinical documentation improvement to ensure compliant, cost-effective care. Located in the United States.