Inpatient DRG Sr Reviewer
Sapphire Digital
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See open jobs at Sapphire Digital.See open jobs similar to "Inpatient DRG Sr Reviewer" Greycroft.About Us
Zelis is modernizing the healthcare financial experience in the United States (U.S.) 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 health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers in the U.S. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts—driving real, measurable results for clients.
Why We Do What We Do
In the U.S., consumers, payers, and providers face significant challenges throughout the healthcare financial journey. Zelis helps streamline the process by offering solutions that improve transparency, efficiency, and communication among all parties involved. By addressing the obstacles that patients face in accessing care, navigating the intricacies of insurance claims, and the logistical challenges healthcare providers encounter with processing payments, Zelis aims to create a more seamless and effective healthcare financial system.
Zelis India plays a crucial role in this mission by supporting various initiatives that enhance the healthcare financial experience. The local team contributes to the development and implementation of innovative solutions, ensuring that technology and processes are optimized for efficiency and effectiveness. Beyond operational expertise, Zelis India cultivates a collaborative work culture, leadership development, and global exposure, creating a dynamic environment for professional growth. With hybrid work flexibility, comprehensive healthcare benefits, financial wellness programs, and cultural celebrations, we foster a holistic workplace experience. Additionally, the team plays a vital role in maintaining high standards of service delivery and contributes to Zelis’ award-winning culture.
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.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:
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
This job is no longer accepting applications
See open jobs at Sapphire Digital.See open jobs similar to "Inpatient DRG Sr Reviewer" Greycroft.