DRG Clinical Validation Lead

Elevance Health•Indianapolis, IN

3d•$89,520 - $161,136•Remote

About The Position

The DRG Clinical Validation Lead ensures medically appropriate, high-quality, cost-effective care by assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out-of-network services, and the appropriateness of treatment settings. The role applies medical policies and industry standards, interprets benefits and managed care products, and guides members to appropriate providers, programs, or community resources. The lead works with medical directors on care appropriateness and accurate claims payment and may manage appeals for denied services. This position conducts utilization reviews, supports access to medically necessary care, collaborates with clinical reviewers, medical directors, and providers, and facilitates discharge planning and care transitions. It serves as the team lead for complex medical issues and may lead cross-functional initiatives and process improvement activities. The role is described as virtual full-time, subject to required in-person training and the employer's commuting-distance policy.

Requirements

Associate degree in nursing and at least 7 years of acute care clinical experience, or an equivalent combination of education and experience.
Prior managed care experience.
Current unrestricted RN license in applicable state(s).

Nice To Haves

One or more of the following certifications: 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 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.
Lead experience.

Responsibilities

Conduct pre-certification, retrospective, out-of-network, and treatment-setting appropriateness reviews for compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts.
Ensure members have access to medically necessary, quality healthcare in a cost-effective setting according to their contracts.
Consult with clinical reviewers and/or medical directors to support medically appropriate, high-quality, cost-effective care throughout the medical management process.
Collaborate with providers to assess members' needs and support early identification and proactive discharge planning.
Facilitate member care transitions across the healthcare continuum and refer treatment plans or plans of care to clinical reviewers as required; does not issue non-certifications.
Support accreditation by understanding, interpreting, and applying accrediting and regulatory requirements and standards.
Serve as team lead and respond to the most complex medical issues.
Ensure consistency in benefit application.
May lead cross-functional teams, projects, initiatives, and process improvement activities.
May serve as a departmental liaison to other business-unit areas or as a representative on enterprise initiatives.
May manage appeals for services denied.