Hybrid Clinical Validation Auditor – RN, CDI, MS-DRG, AP-DRG, APR-DRG

at Elevance Health

• Job title: Clinical Validation Auditor – RN, CDI, MS-DRG, AP-DRG, APR-DRG
• Job type: Full Time
• Experience level: Senior, Lead
• Salary: $86,560 - $155,808 per year
• Degree requirement: Bachelor's Degree
• Location requirements: Hybrid, Denver, United States

About the role

• Clinical Validation Auditor-RN auditing inpatient medical records to ensure accurate clinical documentation. Role requires extensive experience in claims auditing and knowledge of DRGs.

Responsibilities

• Responsible for auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed.
• Specializes in review of Diagnosis Related Group (DRG) paid claims.
• 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

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

• Health insurance
• 401(k) matching
• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• Paid holidays
• Paid Time Off
• Wellness programs
• Financial education resources