Senior DRG Audit Lead — Remote

Elevance Health; Cleveland (OH); Hybrid; USD 122,000 - 183,000; Full time

Job summary

Elevance Health is seeking a Clinical Auditor Principal to audit inpatient medical records and DRG-based paid claims across lines of business. This role requires advanced ICD-10 coding expertise and independent, high-quality audit output in a hybrid/remote setup with in-person training as needed.

The position demands 10+ years' experience with ICD-9/10CM and MS-/AP-/APR-DRG, RHIA/RHIT/CCS/CIC certification, and strong review skills.

Qualifications

• Requires AA/AS or minimum of 15 years of experience in claims auditing, quality assurance, or recovery auditing.
• RHIA certification as a Registered Health Information Administrator, RHIT as a Registered Health Information Technician, CCS as a Certified Coding Specialist, CIC as a Certified Inpatient Coder, or CCDS.
• Minimum of 10 years experience with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG.

Responsibilities

• Audits inpatient medical records and DRG-driven claims.
• Substantiates sophisticated conclusions with ICD-10 coding guidelines and clinical standards.
• Uses audit tools and workflow systems to generate audit findings letters.
• Validates accuracy and quality standards for auditing and documentation purposes.
• Identifies new claim types and opportunities for recoveries and process improvements.
• Operates largely independently with high-quality output.
• Performs secondary audits and supports knowledge sharing across the team.
• Collaborates with management to improve selection criteria.

Skills

ICD-10 coding

DRG auditing

Auditing expertise

Independent work

Education

RHIA/RHIT/CCS/CIC/CCDS certification

AA/AS or 15 years experience

RN license (preferred)

Job description

Elevance Health is seeking a Clinical Auditor Principal to audit inpatient medical records and DRG-based paid claims across lines of business. This role requires advanced ICD-10 coding expertise and independent, high-quality audit output in a hybrid/remote setup with in-person training as needed.

The position demands 10+ years' experience with ICD-9/10CM and MS-/AP-/APR-DRG, RHIA/RHIT/CCS/CIC certification, and strong review skills.