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About the Role
The Diagnosis Related Group Clinical Validation Auditor-RN is responsible for auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed. This role specializes in the review of Diagnosis Related Group (DRG) paid claims.
Responsibilities
- Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities.
- Draws on advanced ICD-10 coding expertise, mastery of clinical guidelines, and industry knowledge to substantiate conclusions.
- Utilizes audit tools, auditing workflow systems and reference information to generate audit determinations and formulate detailed audit findings letters.
- Maintains accuracy and quality standards as established by audit management.
- Identifies potential documentation and coding errors by recognizing aberrant coding and documentation patterns such as inappropriate billing for readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs).
- Suggests and develops high quality, high value, concept and or process improvement and efficiency recommendations.
Requirements
- Requires current, active, unrestricted Registered Nurse license in applicable state(s).
- Requires a minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement, and a minimum of 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG; or any combination of education and experience, which would provide an equivalent background.
Skills
- ICD-10 coding expertise
- Clinical guidelines mastery
- Industry knowledge
- Audit tools utilization
- Auditing workflow systems utilization
- Reference information utilization
- Third party DRG Coding and/or Clinical Validation Audits experience
- Hospital clinical documentation improvement experience
- Broad knowledge of clinical documentation improvement guidelines
- Medical claims billing and payment systems knowledge
- Provider billing guidelines knowledge
- Payer reimbursement policies knowledge
- Coding terminology knowledge
Location
- California
- Colorado
- Illinois
- Maryland
- Nevada
- New York
- Virginia
Work Type
- Virtual
- Hybrid
Experience Level
- Minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement
- Minimum of 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG
Education Level
- Registered Nurse license
Salary/Compensations
- $86,560 - $155,808
Benefits
- Comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical
- Dental
- Vision
- Short and long term disability benefits
- 401(k) +match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
About the Company
- Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler.
- A Fortune 25 company with a longstanding history in the healthcare industry.
- Creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates.
- Values and behaviors are the root of our culture.
- Offer a range of market-competitive total rewards.
Equal Opportunity
- Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.
- Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
- Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.