Impress employers and recruiters.
Choose from hundreds of resume examples.
Impress employers and recruiters.
Choose from hundreds of resume examples.
Tailor your resume to this DRG Clinical Validation Lead role.
Rezi rewrites your resume against Elevance Health's job description. Free.
Tailor your resume to this DRG Clinical Validation Lead role.
Rezi rewrites your resume against Elevance Health's job description. Free.
Don't guess if your resume is good enough.
See how it scores against the DRG Clinical Validation Lead posting at Elevance Health — free, in seconds.
Don't guess if your resume is good enough.
See how it scores against the DRG Clinical Validation Lead posting at Elevance Health — free, in seconds.
About the Role
The DRG Clinical Validation Lead ensures medically appropriate, high quality, and cost-effective care by assessing the medical necessity of various services. This role involves interpreting benefits, guiding members to appropriate resources, and collaborating with medical directors on care appropriateness and claims payment. The position may also involve managing appeals for denied services.
Responsibilities
- Conducts pre-certification, retrospective, out of network, and appropriateness of treatment setting reviews to ensure compliance with criteria, medical policy, and member eligibility, benefits, and contracts.
- Ensures member access to medically necessary, quality healthcare in a cost-effective setting according to contract.
- Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost-effective care throughout the medical management process.
- Collaborates with providers to assess member’s needs for early identification of and proactive planning for discharge planning.
- Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required.
- Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
- Serves as the team lead and responds to the most complex medical issues.
- Ensures consistency in benefit application.
- May lead cross-functional teams, projects, initiatives, and process improvement activities.
- May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives.
Requirements
- Requires AS in nursing and a minimum of 7 years of acute care clinical experience; or any combination of education and experience which would provide an equivalent background.
- Prior managed care experience required.
- Current unrestricted RN license in applicable state(s) required.
Skills
- Registered Health Information Technician (RHIT)
- Registered Health Information Administrator (RHIA)
- Certified Clinical Documentation Specialist (CCDS)
- Certified Documentation Improvement Practitioner (CDIP)
- Certified Professional Coder (CPC)
- Inpatient Coding Credential such as CCS or CIC
- Third party DRG Coding and/or Clinical Validation Audits
- Hospital clinical documentation improvement experience
- Broad knowledge of clinical documentation improvement guidelines
- Medical claims billing and payment systems
- Provider billing guidelines
- Payer reimbursement policies
- Coding terminology
- Lead experience
Location
- California
- Illinois
- Maryland
- Minnesota
- Nevada
- New York
- Washington State
Work Type
- Virtual
- Hybrid
Experience Level
- 7 years of acute care clinical experience
- Lead experience
Education Level
- AS in nursing
Salary/Compensations
- $89,520 to $161,136
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 designed to advance strategy and lead to personal and professional growth.
- Offers 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.
- Applicants who require accommodation to participate in the job application process should submit the Accessibility Accommodation Request Form.
- 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.