DRG Coding Auditor Principal

About the position DRG Coding Auditor Principal Virtual: This role enables associates to work virtually full-time, with the exception of 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. 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. Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending. The DRG Coding Auditor Principal is responsible for auditing inpatient medical records on claims paid based on Diagnostic Relation Group (DRG) methodology, including case rate and per diem, generating highly complex audit findings recoverable claims for the benefit of the Company, for all lines of business, and its clients. Specializes in review of DRG coding via medical record and attending physician’s statement provided by acute care hospitals on paid DRG, especially on very complex coding cases that are paid using APS-DRG, APR-DRG, AP-DRG, MS-DRG or TRICARE methodology and findings may be so complex and advanced that disputes or appeals may only be reviewed by other DRG Coding Audit Principals (or Executives). How you will make an impact: Analyzes and audits claims by integrating advanced or convoluted medical chart coding principles (found in the Official Coding Guidelines, Coding Clinics, and the ICD-10 Alphabetic and Tabular Indices), complex clinical guidelines and maintaining objectivity in the performance of medical audit activities. Draws on extremely advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate sophisticated conclusions. Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters. Validates accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing) on lower level auditors. 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 Hospital Acquired Conditions (HACs), Preventable Adverse Events (PAEs) or Never Events. Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations. Operates largely independently and autonomously with little oversight due to extremely high quality output and audit results that only the most advanced and experienced DRG Coding Auditors would understand. Performs secondary audits on claims that have been reviewed by other DRG Coders for missed opportunities and identifies gaps in foundational audit knowledge. Collaborates with management to improve selection criteria.

Responsibilities

• Analyzes and audits claims by integrating advanced or convoluted medical chart coding principles (found in the Official Coding Guidelines, Coding Clinics, and the ICD-10 Alphabetic and Tabular Indices), complex clinical guidelines and maintaining objectivity in the performance of medical audit activities.
• Draws on extremely advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate sophisticated conclusions.
• Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters.
• Validates accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing) on lower level auditors.
• 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 Hospital Acquired Conditions (HACs), Preventable Adverse Events (PAEs) or Never Events.
• Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations.
• Operates largely independently and autonomously with little oversight due to extremely high quality output and audit results that only the most advanced and experienced DRG Coding Auditors would understand.
• Performs secondary audits on claims that have been reviewed by other DRG Coders for missed opportunities and identifies gaps in foundational audit knowledge.
• Collaborates with management to improve selection criteria.

Requirements

• Requires at least one of the following: AA/AS or minimum of 15 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, RHIT certification as a Registered Health Information Technician, CCS as a Certified Coding Specialist, CIC as a Certified Inpatient Coder, or Certified Clinical Documentation Specialist (CCDS).
• Requires minimum of 10 years experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG.

Nice-to-haves

• BA/BS preferred.
• Experience with vendor based DRG Coding / Clinical Validation Audit setting or hospital coding or quality assurance environment preferred.
• Broad, deep and niche knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology strongly preferred.

Benefits

• 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).
• 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.

Apply tot his job Apply To this Job