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Director, Payment Integrity- DRG Validation (Dir Program Management)

_Location: Alternate locations may be considered. This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations._

The **Director, Payment Integrity- DRG Validation** will lead a team of talented auditors and clinical professionals in protecting the integrity of healthcare payments across our enterprise. The ideal candidate is an experienced, mission-driven leader who thrives in a fast-paced, data-informed environment and is passionate about quality, accuracy, and operational excellence.

How you will make an impact:

+ Drive enterprise-wide DRG validation strategies that directly reduce improper payments and protect healthcare affordability for our members and partners.

+ Develop, inspire, and retain and high-performing team of DRG coding validation, clinical validation, and readmission auditors through coaching, mentoring, and development.

+ Serve as a go-to expert for DRG validation policy, audit escalation, and vendor management, influencing outcomes across clinical, operational, and compliance channels.

+ Collaborate across business units- including Medical Management, Compliance, Claims, and Data & Analytics- to optimize audit effectiveness and transparency.

+ Use data-driven insights to identify trends, gaps, and emerging risks in DRG assignments, leading targeted initiatives for process and accuracy improvements.

+ Hires, trains, coaches, counsels, and evaluates performance of direct reports

Minimum Requirements:

Requires a BA/BS in a related field and minimum of 9 years project/program management experience; minimum of 3 years management experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

+ Bachelor's degree in Nursing, Health Information Management, Healthcare Administration, or related field strongly preferred.

+ Advanced degree (MBA, MPH, MHA, etc.) preferred.

+ Active RHIA, RHIT, CCS, or CDIP credential strongly preferred.

+ Extensive experience in DRG validation audits, medical coding or clinical documentation improvement strongly preferred.

+ Prior people leadership or management role within payment integrity, health plan, or audit services strongly preferred.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

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.

How We Work

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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

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 [email protected] 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.