Diagnosis Related Group Clinical Validation Auditor

Elevance Health•Cincinnati, OH

6d•Remote

About The Position

The Diagnosis Related Group Clinical Validation Auditor audits inpatient medical records to ensure clinical documentation supports the conditions and Diagnosis Related Groups (DRGs) billed and reimbursed. The role specializes in reviews of DRG-paid claims and uses medical chart coding principles, clinical guidelines, and objective judgment to conduct audits. The auditor applies advanced ICD-10 coding expertise, clinical guideline knowledge, and industry knowledge to support conclusions; uses audit tools, workflow systems, and reference materials to make determinations and prepare detailed audit findings letters; and maintains accuracy and quality standards established by audit management. This role identifies potential documentation and coding errors by recognizing patterns such as inappropriate billing for readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs). It also suggests and develops recommendations for high-quality, high-value improvements to concepts, processes, and efficiency. The position is described as primarily virtual full-time, with required in-person training sessions. Candidates must be within a reasonable commuting distance of the posting location(s), unless an accommodation is granted as required by law. The role is non-management and exempt.

Requirements

Associate of Science or Associate of Arts degree, and at least 8 years of experience in claims auditing, quality assurance, or clinical documentation improvement; equivalent combinations of education and experience may be considered.
At least 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG, or an equivalent combination of education and experience.
Current, active, valid, and unrestricted Registered Nurse license in applicable state(s).

Nice To Haves

One or more preferred certifications: Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC), or an 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.
Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology.

Responsibilities

Audit inpatient medical records to ensure clinical documentation supports billed and reimbursed conditions and DRGs.
Analyze and audit claims using medical chart coding principles, clinical guidelines, and objective judgment.
Apply advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate audit conclusions.
Use audit tools, workflow systems, and reference information to determine audit outcomes and prepare detailed findings letters.
Maintain accuracy and quality standards established by audit management.
Identify potential documentation and coding errors, including patterns involving readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs).
Suggest and develop high-quality, high-value recommendations for concept, process, and efficiency improvements.