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Anthem, Inc. Nurse Audit I/Senior - Clinical DRG Validation Reviewer in Las Vegas, Nevada

Nurse Audit I/Senior - Clinical DRG Validation Reviewer

Location: United States


Requisition #: PS33585

Post Date: 4 days ago

Your Talent. Our Vision. At Amerigroup , a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals,it’s a powerful combination. It’s 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.

Position is work from home, however, must live within commutable distance to an Anthem office.*

Primary duties may include, but are not limited to:

  • Navigatingthrough a medical record for auditing purposes, working knowledge of CPT/HCPCSand ICD- 9 and ICD-10 coding, and medical policy guidelines as it applies toinpatient clinical validation DRG review.

  • Performpost payment audit of submitted medical records.

  • Correlatesreview findings with appropriate actions including provider education andrecovery of monies.

  • Assistswith development of audit tools, policies and procedures and educationmaterials.


  • Requires an AS/BS in nursing; 2-4 years of clinicalnursing experience; or any combination of education and experience, which wouldprovide an equivalent background.

  • Current unrestricted RN license in applicablestate(s) required.

  • Requires knowledge of auditing, accounting andcontrol principles and a working knowledge of CPT/HCPCS and ICD 9 coding andmedical policy guidelines.

  • Certified as a Professional Coder preferred.

  • Medical claims review with prior health carefraud audit/investigation experience preferred.

  • Working Knowledge of DRG Validation highly preferred.

Anthem, Inc. is ranked as one ofAmerica’s Most Admired Companies among health insurers by Fortune magazine andis a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn moreabout our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.