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Elevance Health · 1 day ago

Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)

Mason, OH

Full-time

Hybrid

Senior Level, Lead/Staff

$82K/yr - $155K/yr

10+ years exp

Elevance Health is a health company dedicated to improving lives and communities and making healthcare simpler. 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.

Health CareHealth InsurancePersonal HealthWellness

H1B Sponsor Likely

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

Qualification

ICD-10 coding expertiseClinical documentation improvementClaims auditing experienceRegistered Nurse licenseDRG Coding knowledgeQuality assurance experienceProcess improvementAttention to detailCommunication skillsTeam collaborationProblem-solving skills

Required

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

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 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 preferred

Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred

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

Stock purchase plan

Life insurance

Wellness programs

Financial education resources

Company

Elevance Health

Glassdoor3.6

Elevance Health is an integrated whole-health approach to help people in health journey and address their full range of needs.

Founded in 1944

Indianapolis, Indiana, USA

10001+ employees

https://www.elevancehealth.com

H1B Sponsorship

Elevance Health has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

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Trends of Total Sponsorships

2025 (488)

2024 (604)

2023 (660)

2022 (222)