Clinical Validation Auditor – RN, CDI, MS-DRG, AP-DRG, APR-DRG

Elevance Health

Diagnosis Related Group Clinical Validation Auditor-RN responsible for auditing inpatient medical records supporting conditions and DRGs at Elevance Health. Utilizing advanced coding expertise and audit tools for accurate documentation.

Posted 5/21/2026full-timeMason • California, Maryland, Minnesota, Ohio • 🇺🇸 United StatesSeniorLead💰 $82,232 - $155,808 per yearWebsite

About the role

Key responsibilities & impact

Auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed
Analyzing and auditing claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities
Drawing on advanced ICD-10 coding expertise, mastery of clinical guidelines, and industry knowledge to substantiate conclusions
Utilizing audit tools, auditing workflow systems and reference information 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 coding and documentation patterns such as inappropriate billing for readmissions, inpatient admission status, and Hospital-Acquired Conditions (HACs)
Suggesting and developing high quality, high value, concept and or process improvement and efficiency recommendations

Requirements

What you’ll need

Requires current, active, unrestricted Registered Nurse license in applicable state(s)
Requires a minimum of 10 years of experience in claims auditing, quality assurance, or clinical documentation improvement
Requires a 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 are preferred: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), 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 experience 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

Comp & perks

comprehensive benefits package
incentive and recognition programs
equity stock purchase
401k contribution
Paid Time Off
medical, dental, vision, short and long term disability benefits
stock purchase plan
life insurance
wellness programs
financial education resources

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

ICD-10 codingICD-9 codingMS-DRGAP-DRGAPR-DRGclaims auditingclinical documentation improvementmedical chart codingaudit toolsquality assurance

Soft Skills

attention to detailanalytical skillscommunication skillsproblem-solvingorganizational skillsprocess improvementobjectivitycritical thinkingrecommendation developmentteam collaboration

Certifications

Registered Nurse (RN)Registered Health Information Technician (RHIT)Registered Health Information Administrator (RHIA)Certified Clinical Documentation Specialist (CCDS)Certified Documentation Improvement Practitioner (CDIP)Certified Professional Coder (CPC)Certified Coding Specialist (CCS)Certified Inpatient Coder (CIC)