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Anthem, Inc. DRG Coding Auditor in Fresno, California


SHIFT: Day Job

SCHEDULE: Full-time

Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.

This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health care companies and a Fortune Top 50 Company.

Applicable to Colorado Applicants Only

Annual Salary Range*: $80,640 - $100,800

Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

  • The hourly or salary range is the range Anthem in good faith believes is the range of possible compensation for this role at the time of this posting. The Company may ultimately pay more or less than the posted range. This range is only applicable for jobs to be performed in Colorado. This range may be modified in the future. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

    Location : Remote Based

    The DRG Coding Auditor is responsible for auditing inpatient medical records and generating high quality recoverable claims for the benefit of the company, for all lines of business, and its clients. Also responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding and DRG assignment accuracy. Specializes in review of DRG coding via medical record and attending physician’s statement sent in by acute care hospitals on submitted DRG.

    Primary duties may include, but are not limited to:

    • 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, clinical guidelines, and industry knowledge to substantiate conclusions.

    • Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters.

    • Maintains accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing).

    • Identifies new claim types by identifying potential claims outside of the concept where additional recoveries may be available, such as re-admissions, Inpatient to Outpatient, and HACs.

    • Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations.


Minimum Requirements

  • Requires at least one of the following: AA/AS or minimum of 5 years of experience in claims auditing, quality assurance, or recovery auditing.

  • Requires at least one of the following certifications: RHIA certification as a Registered Health Information Administrator and/or RHIT certification as a Registered Health Information Technician and/or CCS as a Cert Coding Specialist and/or CIC as a Certified Inpatient Coder.

  • Requires 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG.

    Preferred Qualifications

  • BA/BS in Health Information Management or Health Information Technology.

  • Experience with vendor based DRG Coding Audit setting or hospital coding or quality assurance environment preferred.

  • Broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology preferred.

  • Preferred working knowledge and application of industry based DRG coding audit standards with 5-7 years’ experience working with ICD-10, MS-DRG, AP-DRG, APR-DRG and Tricare DRG with understanding of medical claims billing and payment systems, provider billing guidelines, payor (Anthem) reimbursement policies, and coding terminology.

  • Preference for candidates with experience and familiarity with application of Official Coding Guidelines, Coding Clinic guidance, CMS guidance, and other regulatory and compliance mandates to inpatient DRG coding audits.

  • Expert level coding knowledge in the area of DRG coding, including ICD-10-CM and ICD-10-PCS, and basic knowledge of CPT and HCPCS coding.

  • Experience applying DRG auditing principles and objectivity in performance of DRG audits for Payment Integrity functions. Utilizes industry experience and knowledge to apply advanced coding expertise to support audit findings for payment accuracy.

    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. Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

    REQNUMBER: PS60435-California