Clinical Provider Auditor II responsible for examining claims and identifying fraud risks at Elevance Health. Collaborating with internal teams and assisting in training new associates.
About the role
- DRG Clinical (RN) Validation Auditor auditing inpatient medical records to ensure accuracy in billing and reimbursement. Specializing in Diagnosis Related Group (DRG) paid claims with a focus on clinical documentation integrity.
Responsibilities
- Auditing inpatient medical records to ensure clinical documentation supports conditions and DRGs billed and reimbursed
- Specializing in review of Diagnosis Related Group (DRG) paid claims
- Analyzing and auditing claims by integrating medical chart coding principles, clinical guidelines, and objectivity in medical audit activities
- Using advanced ICD-10 coding expertise to substantiate conclusions
- Utilizing audit tools and workflow systems to generate audit determinations and formulate detailed audit findings letters
- Maintaining accuracy and quality standards as established by audit management
- Identifying potential documentation and coding errors by recognizing aberrant patterns
- Suggesting and developing process improvement and efficiency recommendations
Requirements
- Current, active, unrestricted Registered Nurse license
- Minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement
- Minimum of 5 years of experience with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG
- Certifications strongly preferred: Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC), 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
Benefits
- Comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution
- Paid holidays
- Paid Time Off
- Medical, dental, vision insurance
- Short and long term disability benefits
- Wellness programs
- Financial education resources
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