Elevance Health
DiagnosisRelatedGroupClinicalValidationAuditor-RN(CDI,MS-DRG,AP-DRGandAPR-DRG)
Neural analysis suggests this role is
optimal for Senior candidates.
“Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG) at Elevance Health. Skills: Clinical Validation Auditing, DRG Auditing, RN License. Audit inpatient medical records. Ensure clinical documentation supports conditions and DRGs billed”
What You'll Achieve.
Maintain accuracy and quality standards; Substantiate conclusions
Industry & Context.
Analytical skills
Requires current, active, unrestricted Registered Nurse license in applicable state(s), Candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law., Required inperson training sessions, Candidates required to become vaccinated against COVID-19 and Influenza for certain patient/member-facing roles
What They're Looking For.
Must Have
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 Have
Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC), 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, Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology
What You'll Do.
Audit inpatient medical records
Ensure clinical documentation supports conditions and DRGs billed
Specialize in review of DRG paid claims
Analyze and audit claims
Integrate medical chart coding principles
Apply clinical guidelines
Perform medical audit activities
Generate audit determinations
Formulate audit findings letters
Maintain accuracy and quality standards
Identify potential documentation and coding errors
Recognize aberrant coding and documentation patterns
Suggest process improvement recommendations
Develop efficiency recommendations
Full Job Description
**Anticipated End Date:** 2026-06-22 **Position Title:** Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG) **Job Description:** **Title:** Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG) **Virtual:** This role enables associates to work virtually full-time, with the exception of required inperson training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. 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. Specializes in review of Diagnosis Related Group (DRG) 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 develop
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