Diagnosis Related Group Clinical Validation Auditor-RN

$79,268 - $150,192/Yr

Elevance Health - Seven Hills, OH

Full-time - Mid Level

Seven Hills, OH

Insurance Carriers and Related Activities

About the position

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. This position will work a hybrid model (remote and office), and ideal candidates will live within 50 miles of one of our PulsePoint locations. The role requires advanced ICD-10 coding expertise and mastery of clinical guidelines to substantiate conclusions. The auditor will utilize audit tools and workflow systems to generate audit determinations and formulate detailed audit findings letters while maintaining accuracy and quality standards as established by audit management.

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.

Requirements

• Current, active, unrestricted Registered Nurse license in applicable state(s).
• Minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement.
• Minimum of 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG.

Nice-to-haves

• 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
• Paid holidays
• Paid Time Off
• Medical, dental, vision benefits
• Short and long term disability benefits
• Life insurance
• Wellness programs
• Financial education resources