Senior DRG Coding Auditor — Remote Lead

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

Job summary

Elevance Health is seeking a DRG Coding Auditor Principal to audit inpatient medical records and DRG methodology across lines of business, using APS‑DRG, APR‑DRG, AP‑DRG, MS‑DRG or TRICARE frameworks.

The role requires deep ICD‑10 coding knowledge, objective auditing, and a proactive approach to identify recoveries and process improvements. Hybrid work with occasional onsite training is expected.

Qualifications

• Requires AA/AS or 15 years of claims auditing experience.
• Certification: RHIA, RHIT, CCS, CIC, or CCDS.
• Minimum of 10 years experience with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG.

Responsibilities

• Analyzes and audits claims by integrating advanced or convoluted medical chart coding principles (found in the Official Coding Guidelines, Coding Clinics, and the ICD‑10 Alphabetic and Tabular Indices), complex clinical guidelines and maintaining objectivity in the performance of medical audit activities.
• Draws on extremely advanced ICD‑10 coding expertise, clinical guidelines, and industry knowledge to substantiate sophisticated conclusions.
• Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters.
• Validates accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing) on lower level auditors.
• Identifies new claim types by identifying potential claims outside of the concept where additional recoveries may be available, such as re‑admissions, Inpatient to Outpatient, and Hospital Acquired Conditions (HACs), Preventable Adverse Events (PAEs) or Never Events. Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations.
• Operates largely independently and autonomously with little oversight due to extremely high quality output and audit results that only the most advanced and experienced DRG Coding Auditors would understand.
• Performs secondary audits on claims that have been reviewed by other DRG Coders for missed opportunities and identifies gaps in foundational audit knowledge.
• Collaborates with management to improve selection criteria.

Skills

RN license

ICD-9/10CM DRG auditing

Education

AA/AS or 15 years claims auditing experience

BA/BS preferred

Tools

Audit tools/workflow systems

Job description

Elevance Health is seeking a DRG Coding Auditor Principal to audit inpatient medical records and DRG methodology across lines of business, using APS‑DRG, APR‑DRG, AP‑DRG, MS‑DRG or TRICARE frameworks.

The role requires deep ICD‑10 coding knowledge, objective auditing, and a proactive approach to identify recoveries and process improvements. Hybrid work with occasional onsite training is expected.