Inpatient DRG Reviewer
Inpatient DRG Reviewer
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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 Inpatient DRG Reviewer will be primarily responsible for conducting post-service pre-payment and post pay comprehensive inpatient DRG reviews based on industry standard inpatient coding guidelines and rules evidence based clinical criteria plan and policy exclusions. Conduct reviews on inpatient DRG claims as they compare with medical records ICD-10 Official Coding Guidelines AHA Coding Clinic and client specific coverage policies. Conduct prompt claim review to support internal inventory management to achieve greatest savings for clients.What youll do:
Perform comprehensive inpatient DRG validation 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.
Based on the evidence presented in the medical records determine and record the appropriate (revised) Diagnosis Codes Procedure Codes and Discharge Status Code applicable to the claim.
Using the revised codes regroup the claim using provided software to determine the new DRG.
Determine where the regrouped new DRG differs from what was originally claimed by the provider write a customer facing rationale or findings statement highlighting the problems found and justifying the revised choices of new codes and DRG based on the clinical evidence obtained during the review
Document all aspect of audits including uploading all provider communications clinical rationale and/or financial research
Identify new DRG coding concepts to expand the DRG product.
Manage assigned claims and claim report adhering to client turnaround time and department Standard Operating Procedures
Meet and/or exceed all internal and department productivity and quality standards
Recommend new methods to improve departmental procedures
Achieve and maintain personal production and savings quota
Maintain awareness of and ensure adherence to Zelis standards regarding privacy
What youll bring to Zelis:
Registered Nurse licensure preferred
Inpatient Coding Certification required (i.e. CCS CIC RHIA RHIT)
3 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
Understanding of hospital coding and billing rules
Clinical skills to evaluate appropriate Medical Record 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.
Base Salary Range
$79000.00 - $105000.00At 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.
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.
Employment Type
Full-Time
