Inpatient DRG Sr. Reviewer

Position Overview

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.

What you’ll do :

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

What you’ll bring to Zelis :

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

Location and Workplace Flexibility

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.

Base Salary Range

$95,000.00 - $127,000.00

At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role.

Zelis’ full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees’ health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage.