Patient Safety DRG Clinical Validation Auditor

Elevance Health

. Audit inpatient medical records to ensure clinical documentation supports billed and reimbursed conditions and DRGs .

Posted 10/15/2026full-timeUnited StatesSeniorLead💰 $86,560 - $129,840 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates advanced expertise in ICD-10 coding, clinical documentation improvement, and claims auditing, ensuring compliance with industry standards and accuracy in medical billing. Proven ability to analyze and identify documentation errors while suggesting process improvements for efficiency.

Highest-signal resume keywords

ICD-10 Coding ExpertiseClaims Auditing ExperienceRegistered Nurse LicenseCertified Clinical Documentation Specialist (CCDS)Clinical Documentation Improvement Guidelines

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

ICD-9/10CM CodingMS-DRGAP-DRGAPR-DRGClaims AnalysisMedical Chart Coding PrinciplesAudit DeterminationsQuality AssuranceDocumentation ImprovementCoding Terminology

Tools & Technologies

Audit ToolsAuditing Workflow Systems

Certifications & Qualifications

Certified Clinical Documentation Specialist (CCDS)Certified Documentation Improvement Practitioner (CDIP)Certified Professional Coder (CPC)CCSCIC

Industry Keywords

Clinical Documentation ImprovementMedical Claims BillingPayer Reimbursement PoliciesHospital-Acquired Conditions (HACs)Third Party DRG Coding

About the role

Key responsibilities & impact

Audit inpatient medical records to ensure clinical documentation supports billed and reimbursed conditions and DRGs
Review Diagnosis Related Group (DRG) paid claims
Analyze and audit claims using medical chart coding principles, clinical guidelines, and objective medical audit practices
Apply advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions
Use audit tools, auditing workflow systems, and reference information to generate audit determinations and detailed audit findings letters
Maintain accuracy and quality standards established by audit management
Identify potential documentation and coding errors, including inappropriate readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs)
Suggest and develop concept, process improvement, and efficiency recommendations

Requirements

What you’ll need

Current, active, unrestricted Registered Nurse license in applicable state(s)
Minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement
Minimum of 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG
One or more of the following certifications preferred: Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC), or inpatient coding credential such as CCS or CIC
Experience with third party DRG Coding and/or Clinical Validation Audits or hospital clinical documentation improvement preferred
Broad knowledge of clinical documentation improvement guidelines, medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, and coding terminology preferred
Ability to work within a reasonable commuting distance from the posting location(s), unless accommodation is granted as required by law
New candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided

Benefits

Comp & perks

Comprehensive benefits package
Incentive and recognition programs
Equity stock purchase
401k contribution
Merit increases
Paid holidays
Paid Time Off
Incentive bonus programs
Medical benefits
Dental benefits
Vision benefits
Short and long term disability benefits
401(k) + match
Stock purchase plan
Life insurance
Wellness programs
Financial education resources