Clinical Validation Auditor

2 months ago

Cincinnati, Ohio, United States Elevance Health Full time
Job Description

Diagnosis Related Group Clinical Validation Auditor

This role is responsible for auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed. The ideal candidate will have expertise in review of Diagnosis Related Group (DRG) paid claims.

Key Responsibilities:
  • Analyze and audit claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities.
  • Draw on advanced ICD-10 coding expertise, mastery of clinical guidelines, and industry knowledge to substantiate conclusions.
  • Utilize audit tools, auditing workflow systems, and reference information to generate audit determinations and formulate detailed audit findings letters.
  • Maintain accuracy and quality standards as established by audit management.
  • Identify 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).
  • Suggest and develop high-quality, high-value, concept, and process improvement and efficiency recommendations.
Requirements:
  • Requires a HS diploma or equivalent and 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.
  • Requires current, active, unrestricted Registered Nurse license in applicable state(s).
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 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.

Salary Range: $83,440 to $150,192

Locations: California, Colorado, District of Columbia (Washington, DC), Nevada, New York, Washington State

About Elevance Health: Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work: At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes, and drive our shared success – for our consumers, our associates, our communities, and our business.

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