Inpatient DRG Sr Reviewer

• 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 

• Must be available to travel 25% - 50% as required to meet business needs. 

What you will bring: 

Required 

• 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 

Work environment 

• A standard work week exists but with the understanding that additional time/effort outside of the usual parameters can/will occur based upon the overall needs of our clients 

• A standard business environment exists with moderate noise levels. 

• Ability to lift and move approximately thirty (30) pounds on a non-routine basis. 

• Ability to sit for extended periods of time.  

Other: 

• Embody Culture and Values 

Benefits/Perks: 

The well-being of Zelis associates is essential: 

• Industry leading Healthcare 

• Caregiving benefits 

• Family Forming & Reproductive Health Benefits 

• And more!  

• Access to Mental Well-being Resources 

• Savings & Investments (401K) 

• Paid Holidays and PTO 

• Educational Resources 

• Giving programs 

• Opportunities to network and connect 

• Discounts on products and services