DRG Clinical Validation Auditor - RN (CDI, MS-DRG, AP-DRG & APR-DRG)

Elevance Health•Durham, NC

3d•$86,560 - $155,808•Remote

About The Position

The DRG Clinical Validation Auditor - RN audits inpatient medical records to ensure that clinical documentation supports the conditions and Diagnosis Related Groups (DRGs) billed and reimbursed. The role specializes in reviews of DRG paid claims and uses clinical documentation, coding principles, and guidelines to make objective audit determinations. The auditor applies advanced ICD-10 coding expertise and clinical guideline knowledge, uses audit tools and workflow systems to develop findings letters, and maintains the accuracy and quality standards established by audit management. The position also identifies documentation and coding errors, including aberrant patterns involving readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs), and recommends improvements to processes and efficiency. The role is primarily virtual full-time, with required in-person training sessions. Candidates generally must reside within reasonable commuting distance of the posting location or an office, subject to applicable accommodation requirements.

Requirements

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

Nice To Haves

One or more preferred certifications: RHIT, RHIA, CCDS, CDIP, 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 objectivity.
Apply advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate audit conclusions.
Use audit tools, workflow systems, and reference information to generate audit determinations and 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, and efficiency improvements.