Manager of DRG Coding & Clinical Validation Audit

About the role

The Manager of DRG Coding Audit-Program/Project is responsible for overseeing a team that audits inpatient medical records to ensure the accuracy and compliance of Diagnosis-Related Group (DRG) assignments. This role involves setting strategic direction, collaborating with various teams, and leading a team of professionals.

Responsibilities

• Sets the strategic direction for audit methodologies
• Oversight of team development
• Ensures audits meet industry best practices and payer-specific requirements
• Cross-functional collaboration with clinical, compliance, provider engagement, and data analytics teams
• Hires, trains, coaches, counsels, and evaluates performance of direct reports
• Analyzes audit trends, DRG shifts, and uses financial outcomes to inform strategy
• Plans program/project scope and design
• Develops metrics and program/project reporting tools
• Analyzes variance to program/project plan
• Builds documentation to support business objectives and ensure consistency
• Champions local stakeholders and tactical decision-makers
• Suggests and develops high-quality, high-value concept and process improvement recommendations
• Uses advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions

Requirements

• BA/BS and minimum of 5 years experience in project/program management, process reengineering, organizational design, and/or implementation; or any combination of education and experience, which would provide an equivalent background
• Minimum of 5-7 years of inpatient coding or DRG auditing experience, including 2-3 years in a leadership or supervisory capacity
• Broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, billing validation criteria, and coding terminology preferred

Preferred Skills, Capabilities And Experiences

• Preferred experience includes a minimum of 5-7 years of inpatient coding or DRG auditing experience, including 2-3 years in a leadership or supervisory capacity
• Broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, billing validation criteria, and coding terminology preferred

Benefits

Carelon Payment Integrity is a proud member of the Elevance Health family of companies. As a leader in the healthcare industry, we offer a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and a 401(k) match. Additionally, we provide a range of benefits such as medical, dental, vision, short and long-term disability, life insurance, wellness programs, and financial education resources. For candidates working in person or virtually in the specified locations, the salary range for this position is $115,020 to $207,216.

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.

Equal Employment Opportunity

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 elevancehealthjobssupport@elevancehealth.com for assistance.