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DRG Coding Auditor (DIAGNOSTIC RELATED GROUP)

This position will work virtually. Alternate locations may be considered. The Ideal candidate must live within 50 miles of one of our Elevance Health PulsePoint locations.

Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending.

The DRG Coding Auditor is responsible for auditing inpatient medical records and generating high quality recoverable claims for the benefit of the company, for all lines of business, and its clients. Also responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding and DRG assignment accuracy. Specializes in review of DRG coding via medical record and attending physician’s statement sent in by acute care hospitals on submitted DRG.

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, clinical guidelines, and industry knowledge to substantiate conclusions.

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

• Maintains accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing).

• 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 HACs.

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

Minimum Requirements:

• Requires at least one of the following: AA/AS or minimum of 5 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 and/or RHIT certification as a Registered Health Information Technician and/or CCS as a Certified Coding Specialist and/or CIC as a Certified Inpatient Coder.

• Requires 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG.

Preferred Skills, Capabilities and Experiences :

• BA/BS preferred.

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

• Broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology preferred.

• Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

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.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. 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.