Remote DRG Clinical Validation Lead

Elevance Health; Virginia (MN); Remote; USD 90,000 - 161,000; Full time

Benefits offered by this job

Comprehensive benefits package

401(k) match

Stock purchase plan

Job summary

Elevance Health is seeking a DRG Clinical Validation Lead to oversee medical necessity reviews for inpatient and outpatient services, ensuring quality and cost-effective care per policy and industry standards.

You will collaborate with medical directors, manage complex clinical questions, and participate in accreditation processes. Requires a current RN license and at least 7 years of acute care experience; preferred coding/documentation credentials may be beneficial.

Qualifications

• Requires AS in nursing and minimum of 7 years of acute care clinical experience; prior managed care experience required.

Responsibilities

• Conducts pre-certification, retrospective, out of network and appropriateness reviews to ensure criteria compliance.
• Ensures access to medically necessary, quality care in a cost-effective setting.
• Collaborates with medical directors to ensure appropriate, high-quality care.
• Leads cross-functional teams and process improvement initiatives.

Skills

RN license

Acute care experience

Managed care

Drg coding experience

Clinical validation

Education

AS in nursing

Tools

RHIT/RHIA/CDDS/CDIP/CPC

DRG Coding

Job description

Elevance Health is seeking a DRG Clinical Validation Lead to oversee medical necessity reviews for inpatient and outpatient services, ensuring quality and cost-effective care per policy and industry standards.

You will collaborate with medical directors, manage complex clinical questions, and participate in accreditation processes. Requires a current RN license and at least 7 years of acute care experience; preferred coding/documentation credentials may be beneficial.