Inpatient DRG Reviewer

Responsibilities

• Perform comprehensive inpatient DRG validation Quality Assurance reviews to determine accuracy based on industry standard coding guidelines and clinical evidence.
• Implement and conduct quality assurance programs to ensure accurate results for clients.
• Manage assigned claims and reports while adhering to client turnaround times and department Standard Operating Procedures.
• Serve as a Subject Matter Expert on DRG validation for team members and other departments.
• Prepare and conduct training for new team members and identify new DRG coding concepts to expand the product.
• Recommend efficiencies and process improvements to enhance departmental procedures.

Requirements

• Inpatient Coding Certification is required (e.g., CCS, CIC, RHIA, or RHIT).
• Strong understanding of hospital coding and billing rules, including ICD-10 CM, MS-DRG, and APR-DRG.
• Knowledge of Medicare guidelines and various healthcare programs.
• Clinical and critical thinking skills to evaluate appropriate coding from medical records.
• Excellent verbal and written communication skills with strong organizational skills.
• Ability to work onsite in a restricted zone environment.

Preferred Qualifications

• Registered Nurse (RN) licensure.
• 5+ years of experience reviewing or auditing ICD-10 CM, MS-DRG, and APR-DRG claims.
• Experience with audit techniques, identification of revenue opportunities, and financial negotiation with providers.

Benefits

• Industry-leading healthcare including caregiving and family forming benefits.
• Access to mental well-being resources.
• Paid holidays and PTO.
• Educational resources and professional development opportunities.
• Financial wellness programs and giving programs.

About the Company

Zelis is modernizing the healthcare financial experience in the United States across payers, providers, and healthcare consumers. We serve more than 750 payers and millions of healthcare providers through a platform of technology-driven solutions designed to identify, optimize, and solve healthcare problems holistically.