At Zelis, we Get Stuff Done. So, let's get to it! 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. 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 you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are. Position Overview Job Description Summary
The DRG Validation 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, and plan and policy exclusions.
KEY RESPONSIBILITIES:
- 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'
- 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
TECHNICAL SKILLS/ KNOWLEDGE:
- Recommended: Nursing degree or equivalent
- Inpatient Coding Certification required (i.e. CCS, CIC, RHIA, RHIT)
- 3-5 years of experience in Inpatient coding
- 3-5 years of experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs
- 4+ 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
- 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 skill
INDEPENDENCE/ ACCOUNTABILITY:
- Regularly reviews goals and objectives with supervisor
- Must have professional manner and respect the confidentiality of administrative matters and files
- Ability to manage and prioritize multiple tasks
- Ability to work under pressure and meet deadlines
- Ability to follow detailed instructions on assignments
COMMUNICATION SKILLS:
- Must work well with others
- Communicates accurately, honestly, and effectively, both in oral and written form, practices active listening
- Clearly conveys information and ideas through a variety of media to individuals and groups in a manner that engages the audience and helps them understand the information
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 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.
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 don't 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 TalentAcquisition@zelis.com. 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.
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Zelis Healthcare, LLC
Jun 20, 2025