Inpatient DRG Validator (Acute Care)

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. Candidates must be within a reasonable commuting distance from the posting location(s) unless an accommodation is granted as required by law.

About the Role

The Inpatient DRG Validator is responsible for auditing inpatient medical records and generating high-quality recoverable claims for the benefit of the company, all lines of business, and its clients. This role involves performing clinical reviews of medical records and other documentation to evaluate issues of coding and DRG assignment accuracy, specializing in the review of DRG coding via medical records and attending physician’s statements submitted by acute care hospitals.

Responsibilities

• 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, 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 recognizing 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.

Requirements

• Requires at least one of the following: AA/AS or a minimum of 5 years of experience in claims auditing, quality assurance, or recovery auditing.
• Requires at least one of the following certifications: RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician), CCS (Certified Coding Specialist), or CIC (Certified Inpatient Coder).
• Requires 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG.

Preferred Qualifications

• BA/BS preferred.
• Experience with vendor-based Diagnosis-Related Group (DRG) Coding/Clinical Validation Audit setting, 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 an emphasis on negotiation, preferred.

Pay

For candidates working in person or virtually in Colorado, Illinois, Maryland, Minnesota, or Nevada, the salary range for this position is $95,172 to $149,556. The salary offered is based on legitimate, non-discriminatory factors set by the company, including geographic location, work experience, education, and skill level.

Benefits

• Comprehensive benefits package, including medical, dental, vision, short- and long-term disability, and 401(k) with company match.
• Incentive and recognition programs.
• Equity stock purchase plan.
• Paid holidays and Paid Time Off (PTO).
• Wellness programs and financial education resources.

Schedule

This role operates under a Hybrid Workforce Strategy. Associates are required to work at an Elevance Health location at least once per week, with specific requirements discussed during the hiring process. The role is primarily virtual, with mandatory in-person training sessions.