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DRG Validation Manager

Sapphire Digital

Sapphire Digital

Multiple locations
Posted on Tuesday, June 11, 2024

Position Overview:

The Manager, DRG Validation of the Expert Claims Review (ECR) department is responsible for daily operations and team management of the DRG product. The Manager, DRG Validation will be primarily responsible for the oversight of DRG validation reviews to ensure accurate and compliant coding based on industry standard inpatient coding guidelines and rules, evidence based clinical criteria, and policy exclusions. Focus will be on analyzing and executing on current business and new client implementations, establishing, and monitoring team performance metrics and ensuring client needs are met.

Key Responsibilities:

  • Oversee the DRG validation process including management of claim assignment and queues, adherence to client turnaround time and department procedures
  • Serve as the Subject Matter Expert on DRG validation to team members and other departments within the organization
  • Lead and manage a team of coding professionals by providing guidance, training, and support to encourage a positive and collaborative team culture
  • Monitor key performance indicators to track team productivity and accuracy, client and concept trends and implement improvement strategies
  • Implement and conduct quality assurance program to ensure accurate results to our clients
  • Collaborate with Product, IT, Implementation and Sales teams to drive growth initiatives and outcomes
  • Assist in dispute process and defense of denials as necessary
  • Must remain current in all national coding guidelines including Official Coding Guidelines, AHA Coding Clinic and AMA CPT Assistant
  • Participate in client facing meetings as necessary
  • Identify new DRG coding concepts to drive growth opportunities.
  • Recommend efficiencies and process improvements to improve departmental procedures
  • Maintain awareness of and ensure adherence to Zelis standards regarding privacy

Skills, Knowledge, and Experience:

  • Registered Nurse licensure required
  • Inpatient Coding Certification required (i.e., CCS, CIC, RHIA, RHIT)
  • 5 - 7 years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims required
  • Supervisory experience preferred
  • Solid understanding of audit techniques and identification of revenue opportunities
  • 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
  • Experience conducting root cause analysis and identifying solutions
  • Strong organization skills with attention to detail
  • Outstanding verbal and written communication skills

As a leading payments company in healthcare, we guide, price, explain, and pay for care on behalf of insurers and their members. We’re Zelis in our pursuit to align the interests of payers, providers, and consumers to deliver a better financial experience and more affordable, transparent care for all. We partner with more than 700 payers, including the top-5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, over 4 million providers, and 100 million members, enabling the healthcare industry to pay for care, with care. Zelis brings adaptive technology, a deeply ingrained service culture, and a comprehensive navigation through adjudication and payment platform to manage the complete payment process.

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 TalentAcquisition@zelis.com

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