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 will 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

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

What you will bring:

• 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. 

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 of 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.

Zelis is modernizing the healthcare financial experience by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. This platform serves more than 750 payers, including the top 5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts – driving real, measurable results for clients.

Commitment to Diversity, Equity, Inclusion, and Belonging 
At Zelis, we champion diversity, equity, inclusion, and belonging in all aspects of our operations. We embrace the power of diversity and create an environment where people can bring their authentic and best selves to work. We know that a sense of belonging is key not only to your success at Zelis, but also to your ability to bring your best each day.

Equal Employment Opportunity  
Zelis is proud to be an equal opportunity employer. All 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 encourage members of traditionally underrepresented communities to apply, even if you do not believe you 100% fit the qualifications of the position, including women, LGBTQIA people, people of color, and people with disabilities.  

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 [email protected]   

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