Inpatient DRG Sr. Reviewer

At Zelis, we Get Stuff Done. So, let's get to it!

Zelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients.

You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are.

As part of the Price Optimization division, this role is responsible for conducting post-service, pre-payment and post pay comprehensive inpatient DRG Quality Assurance reviews in an effort to increase the savings achieved for Zelis clients. Conduct reviews on inpatient DRG claims as they compare with medical records utilizing ICD-10 Official Coding Guidelines, AHA Coding Clinic evidence based clinical criteria and client specific coverage policies.

• Perform comprehensive inpatient DRG validation Quality Assurance reviews to determine accuracy of the DRG billed, based on industry standard coding guidelines and the clinical evidence supplied by the provider in the form of medical records such as physician notes, lab tests, images (x-rays etc.), and with due consideration to any applicable medical policies, medical best practice, etc.

• Implement and conduct quality assurance program to ensure accurate results to our clients

• Manage assigned claims and claim report, adhering to client turnaround time, and department Standard Operating Procedures

• Serve as the Subject Matter Expert on DRG validation to team members and other departments within the organization

• Prepare and conduct training for new team members

• Identify new DRG coding concepts to expand the DRG product

• Meet and/or exceed all internal and department productivity and quality standards

• Must remain current in all national coding guidelines including Official Coding Guidelines, AHA Coding Clinic and AMA CPT Assistant

• Recommend efficiencies and process improvements to improve departmental procedures

• Maintain awareness of and ensure adherence to Zelis standards regarding privacy

• Registered Nurse licensure preferred

• Inpatient Coding Certification required (i.e., CCS, CIC, RHIA, RHIT)

• 5+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferred

• Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers

• Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs

• Strong understanding of hospital coding and billing rules

• Clinical and critical thinking skills to evaluate appropriate coding

• Strong organization skills with attention to detail

• Excellent communication skills both verbal and written, and skilled at developing and maintaining effective working relationships.

• Demonstrated thought leadership and motivation skills, a self-starter with an ability to research and resolve issues

Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future.

We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies.

$95,000.00 - $

At Zelis we are committed to providing fair and…