DRG Coding Auditor

Elevance Health•Ashburn, IL

9d•Remote

About The Position

DRG CODING AUDITOR Virtual : This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending. The DRG CODING AUDITOR is responsible for auditing inpatient medical records and generating high quality recoverable claims for the benefit of the company, for all lines of business, and its clients. Also responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding and DRG assignment accuracy. Specializes in review of DRG coding via medical record and attending physician’s statement sent in by acute care hospitals on submitted DRG. How you will make an impact: 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, clinical guidelines, and industry knowledge to substantiate conclusions. Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters. Maintains accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing). Identifies new claim types by identifying potential claims outside of the concept where additional recoveries may be available, such as re-admissions, Inpatient to Outpatient, and HACs. Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations.

Requirements

Requires at least one of the following: AA/AS or minimum of 5 years of experience in claims auditing, quality assurance, or recovery auditing.
Requires at least one of the following certifications: RHIA certification as a Registered Health Information Administrator and/or RHIT certification as a Registered Health Information Technician and/or CCS as a Certified Coding Specialist and/or CIC as a Certified Inpatient Coder.
Requires 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG.

Nice To Haves

BA/BS preferred.
Experience with vendor based DRG Coding / Clinical Validation Audit setting or hospital coding or quality assurance environment preferred.
Broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology preferred.
Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation 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, clinical guidelines, and industry knowledge to substantiate conclusions.
Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters.
Maintains accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing).
Identifies new claim types by identifying potential claims outside of the concept where additional recoveries may be available, such as re-admissions, Inpatient to Outpatient, and HACs.
Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations.