Managers of DRG Coding & Clinical Validation Audit
About The Position
Manager of DRG Coding Audit-Program/Project Locations: The selected candidate must reside within a reasonable commuting distance of the designated posting location(s): Virginia, Indiana, Georgia, Ohio, District of Columbia (Washington, DC); Maryland; New Jersey, New York and Texas. Hybrid 2: This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office 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 Managers 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 plays a critical part in identifying coding discrepancies and recoverable claim opportunities, and supporting regulatory integrity on behalf of the company and its clients.
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
- Preferred experience includes a 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.
Benefits
- Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
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What This Job Offers
Job Type
Full-time
Career Level
Manager
Number of Employees
5,001-10,000 employees
