Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and
Elevance Health, New York, NY, United States
Diagnosis Related Group Clinical Validation Auditor‑RN (CDI, MS‑DRG, AP‑DRG and APR‑DRG)
Virtual:
This role enables associates to work virtually full‑time, with the exception of required in‑person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work‑life integration, and ensures essential face‑to‑face onboarding and skill development.
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.
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. Specializes in review of Diagnosis Related Group (DRG) paid claims.
How you will make an impact:
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.
Minimum 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.
Preferred Skills, Capabilities and Experiences:
One or more of the following certifications are preferred: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC) or in‑patient coding credential such as CCS or CIC.
Experience with third‑party DRG coding and/or clinical validation audits or hospital clinical documentation improvement experience preferred.
Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred.
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $86,560 to $155,808.
Locations: California; Colorado; Illinois; Maryland; Minnesota; Nevada; New York; Washington State.
In addition to your salary, 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). The salary offered for this specific position is based on a number of legitimate, non‑discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
Vaccination: All new candidates in certain patient/member‑facing roles are required to become vaccinated against COVID‑19 and influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
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 may contact elevancehealthjobssupport@elevancehealth.com for assistance.
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.
#J-18808-Ljbffr
Virtual:
This role enables associates to work virtually full‑time, with the exception of required in‑person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work‑life integration, and ensures essential face‑to‑face onboarding and skill development.
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.
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. Specializes in review of Diagnosis Related Group (DRG) paid claims.
How you will make an impact:
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.
Minimum 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.
Preferred Skills, Capabilities and Experiences:
One or more of the following certifications are preferred: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC) or in‑patient coding credential such as CCS or CIC.
Experience with third‑party DRG coding and/or clinical validation audits or hospital clinical documentation improvement experience preferred.
Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred.
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $86,560 to $155,808.
Locations: California; Colorado; Illinois; Maryland; Minnesota; Nevada; New York; Washington State.
In addition to your salary, 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). The salary offered for this specific position is based on a number of legitimate, non‑discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
Vaccination: All new candidates in certain patient/member‑facing roles are required to become vaccinated against COVID‑19 and influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
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 may contact elevancehealthjobssupport@elevancehealth.com for assistance.
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.
#J-18808-Ljbffr