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　　Diagnosis Related Group (DRG) Clinical Validation Auditor

　　Job Family: Medical and Clinical

　　Type: Full time

　　Date Posted:Jan 23, 2024

　　Anticipated End Date:Feb 19, 2024

　　Reference: JR99910

　　Location:

　　TN, KNOXVILLE

　　CA, WOODLAND HILLS

　　CA, LOS ANGELES

　　MO, ST LOUIS

　　NC, CARY

　　FL, MIAMI

　　IN, INDIANAPOLIS

　　OH, MASON

　　OH, CINCINNATI

　　OH, MASON

　　IL, CHICAGO

　　NY, NEW YORK

　　CO, DENVER

　　NV, LAS VEGAS

　　CT, ROCKY HILL

　　NC, WINSTON

　　IL, CHICAGO

　　GA, ATLANTA

　　TX, AUSTIN

　　DC, WASHINGTON

　　VA, CHESAPEAKE

　　OH, COLUMBUS

　　VA, RICHMOND

　　DC, WASHINGTON

　　NV, LAS VEGAS

　　TX, HOUSTON

　　VA, NORFOLK

　　Description

　　Diagnosis Related Group (DRG) Clinical Validation Auditor

　　Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.

　　The Diagnosis Related Group (DRG) Clinical Validation Auditor is responsible for auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed. Specializes in Diagnosis Related Group (DRG) review of paid claims.

　　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, 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.

　　Minimum Requirements:

　　Requires current, active, unrestricted Registered Nurse license in applicable state(s) and 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.Preferred Skills, Capabilities and Experiences:

　　One or more of the following certifications are preferred: 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.

　　RHIT or RHIA certification preferred.

　　For candidates working in person or remotely in the below locations, the salary* range for this specific position is $80,960 to $145,728.

　　Locations: California; Colorado; Hawaii; Nevada; New York; Washington State; Jersey City, NJ

　　In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws .

　　The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.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 [email protected] for assistance.

　　EEO is the Law

　　Equal Opportunity Employer / Disability / Veteran

　　Please use the links below to review statements of protection from discrimination under Federal law for job applicants and employees.

　　EEO Policy Statement

　　Know Your Rights

　　Pay Transparency

　　Privacy Notice for California Residents

　　Elevance Health, Inc. is anE-verify Employer (https://www.e-verify.gov/sites/default/files/everify/posters/EVerifyParticipationPoster.pdf)

　　Need Assistance?

　　Email us ([email protected])