Senior DRG Clinical Auditor — Remote

Elevance Health; Virginia (MN); Hybrid; USD 122,000 - 183,000; Full time

Benefits offered by this job

Hybrid work model

Comprehensive benefits package

Stock purchase plan

401(k) + match

Paid holidays

Job summary

Elevance Health is seeking a DRG Clinical Auditor Principal to audit inpatient medical records and DRG coding across lines of business. This hybrid role emphasizes highly complex audits and collaboration with management to improve selection criteria.

The position requires extensive ICD-9/10CM and MS-DRG/AP-DRG/AP-DRG experience, with a focus on complex cases and potential disputes or appeals. Hybrid/virtual work is supported with occasional in-person training.

Qualifications

• Requires AA/AS or 15+ years experience in claims auditing, quality assurance, or recovery auditing.
• Certification in RHIA/RHIT/CCS/CIC/CCDS or equivalent is required or preferred.
• RN license strongly preferred; extensive experience with ICD-9/10CM and DRG classifications is expected.

Responsibilities

• Audits inpatient medical records and DRG coding for complex paid claims across lines of business.
• Uses ICD-10 coding guidelines, DRG methodologies, and clinical guidelines to substantiate audit conclusions.
• Generates high-quality audit findings letters and supports process improvement initiatives.
• Collaborates with management to refine selection criteria and audits workflow.

Skills

Auditing

Medical coding

Data analysis

Policy compliance

Education

AA/AS or 15+ years experience

RHIA/RHIT/CCS/CIC/CCDS certifications

RN license (preferred)

Tools

ICD-9/10CM & DRG systems

Job description

Elevance Health is seeking a DRG Clinical Auditor Principal to audit inpatient medical records and DRG coding across lines of business. This hybrid role emphasizes highly complex audits and collaboration with management to improve selection criteria.

The position requires extensive ICD-9/10CM and MS-DRG/AP-DRG/AP-DRG experience, with a focus on complex cases and potential disputes or appeals. Hybrid/virtual work is supported with occasional in-person training.