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As part of the Price Optimization division, this role is 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 plan, and policy exclusions. Conduct reviews on inpatient DRG claims as they compare with medical records ICD-10 Official Coding Guidelines, AHA Coding Clinic and client specific coverage policies. Conduct prompt claim review to support internal inventory management to achieve greatest savings for clients.

• 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.
• Perform readmission reviews, including evaluating prior and current admissions to determine preventability, relatedness, and compliance with readmission policies.
• 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 aspects 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

• RN or LVN required
• Inpatient Coding Certification required (CCS, CIC) within 4 – 6 months of hire date
• 1 -3 years reviewing and or auditing ICD-10 CM, MS-DRG and APPR-DRG claims preferred
• Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs
• Experience performing readmission reviews, including evaluating relatedness, preventability, and compliance with readmission policies
• 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 skills

Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future.

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.

$79,000.00 - $99,750.00

At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role.

Zelis' full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees' health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage.

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.

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.

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.