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Elevance Health · 1 day ago

DRG Coding Auditor Principal

Chicago, IL

Full-time

Hybrid

Senior Level, Lead/Staff

$120K/yr - $207K/yr

10+ years exp

Elevance Health is a health company dedicated to improving lives and communities, and they are seeking a DRG Coding Auditor Principal to audit inpatient medical records on claims paid based on Diagnostic Relation Group (DRG) methodology. The role requires advanced coding expertise to generate complex audit findings and improve claim recovery processes.

Health CareHealth InsurancePersonal HealthWellness

H1B Sponsor Likely

Responsibilities

Analyzes and audits claims by integrating advanced or convoluted medical chart coding principles (found in the Official Coding Guidelines, Coding Clinics, and the ICD-10 Alphabetic and Tabular Indices), complex clinical guidelines and maintaining objectivity in the performance of medical audit activities

Draws on extremely advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate sophisticated conclusions

Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters

Validates accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing) on lower level auditors

Identifies new claim types by identifying potential claims outside of the concept where additional recoveries may be available, such as re-admissions, Inpatient to Outpatient, and Hospital Acquired Conditions (HACs), Preventable Adverse Events (PAEs) or Never Events

Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations

Operates largely independently and autonomously with little oversight due to extremely high quality output and audit results that only the most advanced and experienced DRG Coding Auditors would understand

Performs secondary audits on claims that have been reviewed by other DRG Coders for missed opportunities and identifies gaps in foundational audit knowledge

Collaborates with management to improve selection criteria

Qualification

ICD-10 coding expertiseDRG coding methodologyClaims auditing experienceRHIA certificationCCS certificationClinical guidelines knowledgeQuality assuranceProcess improvementCollaboration skills

Required

Requires at least one of the following: AA/AS or minimum of 15 years of experience in claims auditing, quality assurance, or recovery auditing

Requires at least one of the following certifications: RHIA certification as a Registered Health Information Administrator, RHIT certification as a Registered Health Information Technician, CCS as a Certified Coding Specialist, CIC as a Certified Inpatient Coder, or Certified Clinical Documentation Specialist (CCDS)

Requires minimum of 10 years experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG

Preferred

BA/BS preferred

Experience with vendor based DRG Coding / Clinical Validation Audit setting or hospital coding or quality assurance environment preferred

Broad, deep and niche knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology strongly 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

401(k) +match

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)

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