DRG Coding Auditor - MS-DRG and APR-DRG

Elevance Health•Indianapolis, IN

4d•$92,880 - $160,218•Remote

About The Position

The DRG Coding Auditor audits inpatient medical records and generates high-quality recoverable claims for the company and its clients across all lines of business. The role performs clinical reviews of medical records and other documentation to evaluate coding and DRG assignment accuracy, specializing in reviews of DRG coding based on medical records and attending physician statements submitted by acute care hospitals. This is a primarily virtual, full-time role, except for required in-person training sessions. Alternate locations may be considered for candidates who live within commuting distance of an office. Candidates outside a reasonable commuting distance from the listed posting location(s) will generally not be considered unless an accommodation is granted as required by law.

Requirements

At least one of the following: an AA/AS degree or a minimum of 5 years of experience in claims auditing, quality assurance, or recovery auditing.
At least one of the following certifications: RHIA, RHIT, CCS, CIC, or CCDS.
5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG.

Nice To Haves

BA/BS degree preferred.
Experience in a vendor-based DRG coding or clinical validation audit setting, or in a 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.

Responsibilities

Analyze and audit claims by integrating medical chart coding principles, clinical guidelines, and objectivity in medical audit activities.
Apply advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions.
Use audit tools, workflow systems, and reference information to make audit determinations and generate audit findings letters.
Maintain accuracy and quality standards established by audit management for the auditing concept, valid claim identification, and documentation, including letter writing.
Identify potential claim types outside the existing concept where additional recoveries may be available, such as readmissions, inpatient-to-outpatient cases, and HACs.
Recommend and develop high-quality, high-value concept, process-improvement, and efficiency opportunities.