Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)

Elevance Health•Atlanta, GA

21h•Hybrid

About The Position

The Diagnosis Related Group Clinical Validation Auditor-RN is responsible for auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed. This role specializes in the review of Diagnosis Related Group (DRG) paid claims. This position is virtual full-time, offering maximum flexibility and autonomy, with the exception of required in-person training sessions. This approach aims to promote productivity, support work-life integration, and ensure essential face-to-face onboarding and skill development. Candidates must be within a reasonable commuting distance from the posting location(s) for potential in-person requirements, unless an accommodation is granted by law.

Requirements

Requires current, active, unrestricted Registered Nurse license in applicable state(s).
Requires a minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement, and a minimum of 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

One or more of the following certifications are preferred: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC) or Inpatient Coding Credential such as CCS or CIC.
Experience with third party DRG Coding and/or Clinical Validation Audits or hospital clinical documentation improvement experience preferred.
Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred.

Responsibilities

Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities.
Draws on advanced ICD-10 coding expertise, mastery of clinical guidelines, and industry knowledge to substantiate conclusions.
Utilizes audit tools, auditing workflow systems and reference information to generate audit determinations and formulate detailed audit findings letters.
Maintains accuracy and quality standards as established by audit management.
Identifies potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate billing for readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs).
Suggests and develops high quality, high value, concept and or process improvement and efficiency recommendations.