Manager, DRG Validation
Manager, DRG Validation
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Job Description
At Zelis we Get Stuff Done. So lets get to it!
A Little About Us
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.
A Little About You
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 youve learned along the way. You are more than just your resume; you are a reflection of your achievements the knowledge youve gained and the personal interests that shape who you are.
Position Overview
The Manager DRG Validation of the Expert Claims Review (ECR) department is responsible for daily operations and team management of the DRG product. The Manager DRG Validation will be primarily responsible for the oversight of DRG validation reviews to ensure accurate and compliant coding based on industry standard inpatient coding guidelines and rules evidence based clinical criteria and policy exclusions. Focus will be on analyzing and executing on current business and new client implementations establishing and monitoring team performance metrics and ensuring client needs are met.What youll do:
Oversee the DRG validation process including management of claim assignment and queues adherence to client turnaround time and department procedures
Serve as the Subject Matter Expert on DRG validation to team members and other departments within the organization
Lead and manage a team of coding professionals by providing guidance training and support to encourage a positive and collaborative team culture
Monitor key performance indicators to track team productivity and accuracy client and concept trends and implement improvement strategies
Implement and conduct quality assurance program to ensure accurate results to our clients
Collaborate with Product IT Implementation and Sales teams to drive growth initiatives and outcomes
Assist in dispute process and defense of denials as necessary
Must remain current in all national coding guidelines including Official Coding Guidelines AHA Coding Clinic and AMA CPT Assistant
Participate in client facing meetings as necessary
Identify new DRG coding concepts to drive growth opportunities.
Recommend efficiencies and process improvements to improve departmental procedures
Maintain awareness of and ensure adherence to Zelis standards regarding privacy
What youll bring to Zelis:
Registered Nurse licensure required
Inpatient Coding Certification required (i.e. CCS CIC RHIA RHIT)
5 - 7 years reviewing and/or auditing ICD-10 CM MS-DRG and APR-DRG claims required
Supervisory experience preferred
Solid understanding of audit techniques and identification of revenue opportunities
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
Experience conducting root cause analysis and identifying solutions
Strong organization skills with attention to detail
Outstanding verbal and written communication skills
Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future.
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 employees work locations are based on the needs of the position and determined by the Leadership -office work and activities if applicable vary based on the work and team objectives in accordance with Company policies.
Equal Employment Opportunity
Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race color religion age sex national origin disability status genetics protected veteran status sexual orientation gender identity or expression or any other characteristic protected by federal state or local laws.
We welcome applicants from all backgrounds and encourage you to apply even if you dont meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all.
Accessibility Support
We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process please email .
Disclaimer
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race color religion sex gender identity national origin disability status protected veteran status or any other characteristic protected by law.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities duties and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities duties and skills from time to time.
Required Experience:
Manager
Employment Type
Full-Time
