Manager DRG Coding Validation

Manager DRG Coding Validation

Hybrid 2: This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered.

Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending.

The Manager of DRG Coding Audit & Clinical Validation leads a high-performing team responsible for auditing inpatient medical records to ensure the accuracy and compliance of Diagnosis-Related Group (DRG) assignments. This role plays a critical part in identifying coding discrepancies and recoverable claim opportunities, and supporting regulatory integrity on behalf of the company and its clients.

How you will make an impact:

• Sets the strategic direction for audit methodologies, oversees team development, and ensures that audits meet the industry's best practices and payer-specific requirements.
• Collaborates cross-functionally with clinical, compliance, provider engagement, and data analytics teams to align audit insights with broader program goals.
• Hires, trains, coaches, counsels, and evaluates performance of direct reports.
• Analysis of audit trends, DRG shifts, and using financial outcomes to inform strategy.
• Plans program/project scope and design.
• Develops metrics and program/project reporting tools.
• Analyzes variance to program/project plan.
• Leads building of documentation to support business objectives and ensure consistency.
• Responsible for championing local stakeholders and tactical decision-makers.
• Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations.
• Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions.

Minimum Requirements:

Requires a BA/BS and minimum of 5 years experience in project/program management, process reengineering, organizational design, and/or implementation; or any combination of education and experience, which would provide an equivalent background. Travels to worksite and other locations as necessary.

Preferred Skills, Capabilities and Experiences:

• Preferred experience includes a minimum of 5-7 years of inpatient coding or DRG auditing experience, including 2-3 years in a leadership or supervisory capacity.
• Experience working with ICD-9/10CM, MS-DRG and APR-DRG.
• Broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology preferred.

Job Level: Manager

Workshift: 1st Shift (United States of America)

Job Family: BSP > Program/Project

Elevance Health is a health company dedicated to improving lives and communities and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.