Patient Safety DRG Clinical Validation Auditor

Elevance Health•Indianapolis, IN

17h•$86,560 - $129,840•Remote

About The Position

The Patient Safety DRG Clinical Validation Auditor audits inpatient medical records to ensure clinical documentation supports the conditions and Diagnosis Related Groups (DRGs) billed and reimbursed, specializing in review of DRG-paid claims. The position is described as virtually full-time, with in-person training sessions required. Candidates generally must be within a reasonable commuting distance of the posting locations unless an accommodation is granted as required by law. The auditor analyzes claims using medical chart coding principles, clinical guidelines, and objective audit practices. The role draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to reach and substantiate audit conclusions. It uses audit tools, workflow systems, and reference materials to make determinations and prepare detailed audit findings letters, while meeting established accuracy and quality standards. The position also identifies potential documentation and coding errors, including aberrant patterns involving readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs), and recommends or develops improvements to concepts, processes, and efficiency. The listed salary range for the specified locations is $86,560 to $129,840. Elevance Health describes its benefits as including a comprehensive benefits package and incentive and recognition programs, subject to eligibility requirements.

Requirements

Current, active, unrestricted Registered Nurse license in applicable state(s).
At least 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement, and at least 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG; or an equivalent combination of education and experience.

Nice To Haves

One or more preferred certifications: Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC), or an inpatient coding credential such as CCS or CIC.
Experience with third-party DRG coding and/or clinical validation audits, or hospital clinical documentation improvement experience.
Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology.

Responsibilities

Audit inpatient medical records to verify that clinical documentation supports billed and reimbursed conditions and DRGs, with a focus on DRG-paid claims.
Analyze and audit claims using medical chart coding principles, clinical guidelines, and objective medical-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 prepare detailed audit findings letters.
Maintain the accuracy and quality standards established by audit management.
Identify potential documentation and coding errors and aberrant patterns, including issues involving readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs).
Suggest and develop high-quality, high-value recommendations for concept, process, and efficiency improvements.