Inpatient DRG Validator (Acute Care)

Elevance Health•Indianapolis, NV

4d•$95,172 - $149,556•Remote

About The Position

The Inpatient DRG Validator 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 related documentation to evaluate coding and DRG assignment accuracy, specializing in review of DRG coding based on medical records and attending physician statements submitted by acute care hospitals. The validator analyzes claims using medical chart coding principles, clinical guidelines, and objective audit practices. The role uses advanced ICD-10 coding expertise, audit tools, workflow systems, and reference materials to make audit determinations and produce findings letters. It also identifies potential claims beyond existing audit concepts, including readmissions, inpatient-to-outpatient claims, and hospital-acquired conditions (HACs), and recommends improvements to audit concepts and processes.

Requirements

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

Nice To Haves

BA/BS degree.
Experience in a vendor-based DRG coding or clinical validation audit setting, or in a hospital coding or quality assurance environment.
Broad knowledge of medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, billing validation criteria, and coding terminology.
Knowledge of Plan policies and procedures across benefit program management, with a strong emphasis on negotiation.

Responsibilities

Analyze and audit claims by applying medical chart coding principles, clinical guidelines, and objective audit practices.
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 generate audit findings letters.
Meet audit management accuracy and quality standards for audit concepts, valid claim identification, and documentation, including letter writing.
Identify new claim types and potential recoveries beyond existing concepts, including readmissions, inpatient-to-outpatient claims, and HACs.
Recommend and develop high-quality, high-value improvements to audit concepts, processes, and efficiency.