DRG Clinical Validation Auditor (RN-Claims Reviewer)

Location: Indiana - Indianapolis Nevada - Las Vegas Ohio - Seven Hills Ohio - Mason Texas - Grand Prairie Georgia - Atlanta Maryland - Hanover Kentucky - Louisville Tennessee - Nashville Florida - Miami Ohio - Cincinnati Florida - Tampa Virginia - Norfolk Kansas - Overland Park Job Description: Anticipated End Date: 2026-02-26 Position Title: DRG Clinical Validation Auditor (RN/Claims Reviewer) Job Description: DRG Clinical (RN) Validation Auditor Virtual: This role enables associates to work virtually full-time, except for required in-person 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 locations will not be considered for employment, unless an accommodation is granted as required by law. The 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 review of Diagnosis Related Group (DRG) paid claims. Primary duties may include, but are not limited to: • 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. • Requires a 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; or any combination of education and experience, which would provide an equivalent background. Preferred Skills, Capabilities, and Experiences: • One or more of the following certifications are strongly preferred: • Certified Clinical Documentation Specialist (CCDS), • Certified Documentation Improvement Practitioner (CDIP), • Certified Professional Coder (CPC) and/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. • Bedside Acute care experience strongly preferred. • Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred. For candidates working in person or virtually in the below locations, the salary* range for this specific position is $90,000 to $135,702. Locations: Maryland; Nevada 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 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. Job Level: Non-Management Exempt Workshift: 1st Shift (United States of America) Job Family: MED > Licensed/Certified - Other 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. 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 and Influenza. 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. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Apply tot his job