[Hiring] Inpatient DRG Validator @Elevance Health

Role Description

The Inpatient DRG Validator (Acute Care) is responsible for auditing inpatient medical records and generating high-quality recoverable claims for the benefit of the company and its clients. This role also involves 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.

Qualifications

• 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.

Requirements

• BA/BS preferred.
• Experience with vendor-based Diagnosis-Related Group (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.

Benefits

• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase.
• 401k contribution (all benefits are subject to eligibility requirements).