Inpatient Medical Coding Auditor at Evolent Health

Title: Inpatient Medical Coding Auditor

Location: United States – Remote

time type: Full time

It’s Time For A Change…

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving power that brings us to work each day. We believe in embracing new ideas, testing ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans. Are we growing? Absolutely. We have seen about 30% average growth over the last three years. Are we recognized? Definitely. We were named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019 and are proud to be recognized as a leader in driving important Diversity and Inclusion (D&I) efforts: Evolent achieved a 95% score on its first-ever submission to the Human Rights Campaign’s Corporate Equality Index; was named on the Best Companies for Women to Advance List 2020 by Parity; and we publish an annual Diversity and Inclusion Annual Report to share our progress on how we’re building an equitable workplace. We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

What You’ll Be Doing:

The Inpatient Medical Coding Auditor is responsible for verifying the accuracy of DRG (inpatient) claims reimbursement, coding, and billing in accordance with the Plans’ provider agreements and the National Healthcare Billing Audit guidelines. The Auditor will collaborate with a variety of business units including Market Operations, Claims, Health and Medical Management (including Medical Directors), Network Management and our external Provider community. The successful candidate must be capable of building and maintaining strong working relationships with key internal and external constituents and working effectively in a matrixed environment.


  • Conduct Diagnosis Related Grouper Validation (DRG) audits to verify the accuracy of claims reimbursement by applying National Healthcare Billing Audit standards, ICD-10 -CM/PCS guidelines and related American Hospital Association Coding Clinic guidelines, and the Plans’ agreements including published policies.
  • Select claims samples for medical record reviews in accordance with pre-selection criteria, billing trends, and supporting documentation.
  • Monitor existing/emerging trends and keep relevant stakeholders informed of risk areas and concerns that may require additional attention or result in additional savings.
  • Participates in and/or leads inter-departmental process improvement initiatives. Acting as a subject matter expert with internal and external stakeholders in reference to coding, billing practices, and accuracy of assigned ICD-10 codes and DRGs.
  • Identifies compliance risks and financial opportunities based on chart reviews. Performs concurrent review of hospital bills to document unbilled, under billed, and overbilled items/services
  • Educate stakeholders on post audit findings and close audits in timely manner using audit program databases that incorporate 3M software.
  • Identify potential quality of care issues and service or treatment delays. Make referrals for follow-up as necessary.
  • Identify possible fraud and abuse, document billing errors, and benefit cost management and savings opportunities.
  • Actively participate in internal/external meetings, training activities and other cost and trend initiatives.
  • Identify and pursue new opportunities for cost avoidance savings that contribute to the company’s annual financial and service targets.
  • Meet deadlines and commitments by tightly managing deliverables, coordinating matrixed inputs, and ensuring all tasks are performed to bring projects to timely closure.
  • Represent department on cross functional workgroups and projects as needed.
  • Conduct audits remotely using the EVH Payment Integrity platform and electronic medical record documentation.

The Experience You’ll Need (Required):

  • Active Certified coder (CIC or CCS) required. Candidate would need to maintain active certification.
  • In-depth knowledge of and ability to interpret ICD-10-CM/PCS, HCPCS/CPT, APR-DRG, MS-DRG codes and DRG grouping systems and Plan benefit designs.
  • Ability to travel for onsite audits as needed.
  • 1-2 years’ experience reviewing and auditing medical records, working in a health plan or health insurance, or similar environment.
  • Strong quantitative, analytical, interpersonal, organizational, project management, problem-solving and communication skills.
  • Ability to navigate and manage through difficult, complex conversations with positive outcomes.
  • Strong computer skills: – proficient in MS Word, Excel, PowerPoint and Outlook, familiarity with Electronic Medical Record systems.
  • Ability to work as part of a team with a positive attitude while also able to work independently.

Finishing Touches (Preferred):

  • Clinical Documentation Improvement (CDI/CDEO) certification
  • Hands-on work with complex medical and billing information preferred

Technical requirements:

Currently, Evolent employees work remotely temporarily due to COVID-19. As such, we require that all employees have the following technical capability at their home: High speed internet over 10 MBPS and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.