Manager of DRG Coding & Clinical Validation Audit

Elevance Health•Atlanta, IN

1d•Hybrid

About The Position

Carelon Payment Integrity, a proud member of the Elevance Health family of companies, Carelon Insights (formerly Payment Integrity), is dedicated to recovering, eliminating, and preventing unnecessary medical-expense spending. The Manager of DRG Coding & Clinical Validation leads a high-performing team responsible for auditing inpatient medical records to ensure the accuracy and compliance of Diagnosis-Related Group (DRG) assignments. This role is critical in identifying coding discrepancies, recoverable claim opportunities, and supporting regulatory integrity for the company and its clients. This role operates under a Hybrid 2 model, requiring associates to be in-office 3 days per week to foster collaboration and connectivity, while also providing flexibility for productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.

Requirements

Requires a BA/BS and minimum of 5 years experience in project/program management, process reengineering, organizational design, and/or implementation; or any combination of education and experience, which would provide an equivalent background.
Travels to worksite and other locations as necessary.

Nice To Haves

Minimum of 5-7 years of inpatient coding or DRG auditing experience, including 2-3 years in a leadership or supervisory capacity.
Experience working with ICD-9/10CM, MS-DRG and APR-DRG.
Broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology preferred.

Responsibilities

Sets the strategic direction for audit methodologies, oversees team development, and ensures that audits meet the industry’s best practices and payer-specific requirements.
Collaborates cross-functionally with clinical, compliance, provider engagement, and data analytics teams to align audit insights with broader program goals.
Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Analysis of audit trends, DRG shifts, and using financial outcomes to inform strategy.
Plans program/project scope and design.
Develops metrics and program/project reporting tools.
Analyzes variance to program/project plan.
Leads building of documentation to support business objectives and ensure consistency.
Responsible for championing local stakeholders and tactical decision-makers.
Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations.
Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions.