Inpatient DRG Reviewer

About the role

Zelis is modernizing the healthcare financial experience in the United States (U.S.) 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. At Zelis, AI is woven into the fabric of how we work. Every associate is expected - and empowered - to partner with AI to challenge the status quo, accelerate innovation, and amplify their impact. This is a place for builders with a growth mindset who act with agility, embrace change, and use modern technology to shape smarter solutions, exceptional experiences, and the future of our industry for our clients, customers, and our culture. 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.

Responsibilities

• 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

Requirements

• 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

Benefits

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