Environmental Compliance Auditor
AECOM
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
Elevance Health
full-time
Posted on:
Location: California • 🇺🇸 United States
Visit company websiteSalary
💰 $81,852 - $155,088 per year
Job Level
SeniorLead
About the role
- Audits DRG-related inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed
- Specializes in review of Diagnosis Related Group (DRG) paid claims
- Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities
- Draws on advanced ICD-10 coding expertise, mastery of clinical guidelines, and industry knowledge to substantiate conclusions
- Utilizes audit tools, auditing workflow systems and reference information to generate audit determinations and formulate detailed audit findings letters
- Maintains accuracy and quality standards as established by audit management
- Identifies 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)
- Suggests and develops high quality, high value, concept and or process improvement and efficiency recommendations
Requirements
- Requires 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 with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG; or any combination of education and experience, which would provide an equivalent background
