Diagnosis Related Group Clinical Validation Auditor

Elevance Health•Tampa, FL

8d•Remote

About The Position

The DRG Clinical Validation Auditor audits inpatient medical records to ensure clinical documentation supports billed and reimbursed conditions and Diagnosis Related Groups (DRGs). The role specializes in reviewing DRG paid claims and uses medical chart coding principles, clinical guidelines, and objective judgment to conduct medical audits. The auditor applies advanced ICD-10 coding expertise and industry knowledge, uses audit tools and workflow systems to determine audit outcomes and prepare detailed findings letters, and maintains quality and accuracy standards. The position is primarily virtual, with required in-person training sessions; candidates must be within a reasonable commuting distance of the posting location unless an accommodation is granted. Elevance Health describes its broader workforce strategy as hybrid, but this position is specifically described as primarily virtual.

Requirements

Associate of Science (AS) or Associate of Arts (AA) 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-9/10-CM, 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 of the following 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 verify that clinical documentation supports billed and reimbursed conditions and DRGs.
Analyze claims using medical chart coding principles, clinical guidelines, and objective judgment.
Use advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate audit conclusions.
Use audit tools, workflow systems, and reference information to make audit determinations and prepare detailed audit findings letters.
Maintain accuracy and quality standards established by audit management.
Identify potential documentation and coding errors, including aberrant patterns involving readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs).
Suggest and develop high-quality, high-value recommendations for concept, process improvement, and efficiency.