DRG Coding Auditor at Elevance Health

Chicago, Illinois, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Health InsuranceIndustries

Requirements

AA/AS or minimum of 5 years of experience in claims auditing, quality assurance, or recovery auditing
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)
5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG

Responsibilities

Audit inpatient medical records and generate high quality recoverable claims for all lines of business and clients
Perform clinical reviews of medical records and documentation to evaluate coding and DRG assignment accuracy, specializing in DRG coding reviews from acute care hospitals
Analyze and audit claims by integrating medical chart coding principles, clinical guidelines, and objectivity
Draw on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions
Utilize audit tools, auditing workflow systems, and reference information to make audit determinations and generate audit findings letters
Maintain accuracy and quality standards set by audit management for auditing concepts, valid claim identification, and documentation (e.g., letter writing)
Identify new claim types and potential recoveries outside standard concepts, such as re-admissions, Inpatient to Outpatient transitions, and HACs
Suggest and develop high quality, high value concept, process improvement, and efficiency recommendations

Skills

DRG Coding

ICD-10

Medical Auditing

Inpatient Coding

Clinical Review

Claims Auditing

Medical Records Review

Elevance Health

Integrated health services and digital platform

About Elevance Health

Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.

Indianapolis, IndianaHeadquarters

1944Year Founded

$309.4MTotal Funding

IPOCompany Stage

Enterprise Software, Social Impact, HealthcareIndustries

10,001+Employees

Benefits

Medical, dental, & vision insurance

401(k) + match

Paid holidays

Paid Time Off

Incentive bonus programs

Stock purchase plan

Life insurance

Wellness Programs

Financial education resources

Adoption & Surrogacy Assistance

Dependent-care Flexible Spending Account (DCFSA)

Parental Leave

Parental Transition Week

Critical Caregiving Leave

Risks

Departure of CFO John Gallina may create a gap in financial leadership.

Lawsuit against CMS over MA Star Ratings could lead to financial penalties.

CareBridge integration may face operational challenges, disrupting service delivery.

Differentiation

Elevance Health integrates whole health approach with digital health platform for comprehensive care.

Acquisition of CareBridge enhances home health services within Carelon division.

Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.

Upsides

AI integration in home health services can reduce hospital readmissions and improve outcomes.

Predictive analytics support early disease detection, aligning with Elevance's whole health approach.

Telehealth expansion offers opportunities to reach more patients remotely.

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