Director, DRG Validation

Zelis • St. Petersburg, FL

1d • Hybrid

About The Position

At Zelis, we Get Stuff Done. So, let’s get to it! A Little About Us Zelis is modernizing the healthcare financial experience 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. A Little About You You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are. Position Overview The Director, DRG Validation is responsible for the strategic leadership, operational performance, innovation, and growth of the DRG Validation solution across both pre-pay and post-pay payment integrity programs. This role serves as the enterprise leader for DRG Validation, accountable for product performance, operational execution, quality outcomes, client value realization, and future-state solution development. The Director leads a global organization of coding, clinical, quality, and operational professionals across the United States and India, ensuring scalable delivery, operational excellence, and consistent client outcomes. This role partners closely with Product, Technology, Analytics, Operations, Sales, Client Management, and Clinical leadership to define and execute the long-term vision for DRG Validation. As the senior subject matter expert for inpatient coding and reimbursement integrity, the Director is responsible for advancing innovation through automation, artificial intelligence, machine learning, and workflow transformation initiatives that improve coding accuracy, operational efficiency, scalability, and savings performance. This role translates industry changes, reimbursement trends, client needs, and market opportunities into strategic initiatives that strengthen the DRG Validation solution and support enterprise growth objectives.

Requirements

• Current inpatient coding certification required (CCS, CIC, RHIA, RHIT, or equivalent).
• 12+ years of experience in DRG validation, inpatient coding, reimbursement integrity, clinical audit, or related healthcare functions.
• 5+ years of progressive leadership experience leading managers, supervisors, or large operational teams.
• Demonstrated experience leading large-scale operational transformation, automation, or technology-enabled initiatives.

Nice To Haves

• Active Registered Nurse (RN) licensure preferred.
• Experience leading global teams.
• Experience supporting AI, automation, machine learning, or advanced analytics initiatives within healthcare operations.
• Experience with pre-pay and post-pay payment integrity programs.

Responsibilities

• Own the strategic direction, growth, and performance of the DRG Validation solution across all clients and lines of business.
• Accountable for achieving savings, revenue, and productivity targets for the solution.
• Develop and execute multi-year plans that support organizational growth objectives, client value, operational scalability, and product innovation.
• Establish, monitor, and report on key performance indicators (KPIs) and operational, financial, quality, and client performance metrics, utilizing data-driven insights to identify opportunities, mitigate risks, and drive achievement of strategic and operational goals.
• Partner with executive leadership to identify market opportunities, growth initiatives, and competitive differentiation strategies.
• Translate industry trends, reimbursement changes, coding updates, and regulatory developments into strategic business recommendations.
• Own strategic direction and operational performance across both pre-pay and post-pay DRG Validation programs, ensuring alignment with client objectives, reimbursement integrity goals, and organizational growth strategies.
• Operational Leadership & Performance Management: Lead and develop managers, clinical leaders, coding professionals, and quality teams supporting the DRG Validation function.
• Ensure operational excellence through effective resource planning, productivity management, quality oversight, and performance optimization.
• Drive continuous improvement initiatives that improve accuracy, turnaround times, savings capture, and client outcomes.
• Establish governance processes, operational standards, and scalable workflows to support business growth.
• Oversee quality assurance programs and ensure consistent application of coding and reimbursement standards.
• Lead and develop a globally distributed team across the United States and India, ensuring effective workforce planning, operational consistency, talent development, and scalability.
• Establish organizational structures, succession planning, and performance frameworks that support continued business growth and global delivery strategies.
• Foster a culture of innovation, accountability, collaboration, and continuous improvement across global teams.
• Product, Technology & Innovation: Serve as the executive business owner and strategic stakeholder for DRG Validation product enhancements, automation initiatives, AI-enabled capabilities, and technology investments.
• Partner with Product leadership and Technology teams to define future-state platform capabilities and prioritize investments that improve scalability, quality, operational efficiency, and client value.
• Drive the business requirements and strategic direction for next-generation DRG validation capabilities.
• Drive the identification, development, and implementation of new DRG concepts, reimbursement methodologies, and savings opportunities.
• Provide strategic oversight for machine learning, automation, analytics, and decision-support capabilities related to DRG Validation.
• Innovation, AI & Automation Leadership: Lead the identification, prioritization, and implementation of AI, machine learning, and automation opportunities across DRG Validation operations.
• Partner with Product, Technology, and Analytics teams to modernize DRG review workflows and improve scalability, quality, and productivity.
• Drive the development of technology-enabled solutions that enhance coding accuracy, reduce manual effort, and improve client outcomes.
• Establish a multi-year innovation roadmap for DRG Validation that aligns with organizational automation and digital transformation objectives.
• Evaluate emerging technologies, coding tools, and reimbursement intelligence capabilities to support future-state operational models.
• Client, Market & Growth Leadership: Serve as executive sponsor and subject matter expert for strategic client engagements, implementations, escalations, and growth initiatives.
• Partner with Sales, Client Management, and Implementation teams to support client retention, expansion opportunities, and new business growth.
• Identify trends and opportunities across clients and markets to improve savings performance and strengthen solution positioning.
• Represent the DRG Validation solution during client presentations, industry discussions, and strategic business reviews.
• Data, Analytics & Business Insights: Leverage operational, clinical, coding, and financial data to identify trends, risks, and opportunities.
• Drive data-informed decision making through performance reporting, savings analytics, quality metrics, and client trend analysis.
• Partner with Analytics and BI teams to enhance reporting capabilities and develop actionable business insights.
• Ensure effective measurement and reporting of business outcomes, operational performance, and value realization.
• Compliance, Quality & Governance: Maintain enterprise oversight of coding compliance, quality standards, audit methodologies, and reimbursement integrity.
• Ensure adherence to HIPAA, regulatory requirements, official coding guidelines, Coding Clinic, CPT Assistant guidance, and internal policies.
• Establish governance frameworks that support consistency, accountability, risk mitigation, and operational excellence.
• Oversee dispute management processes and escalation pathways related to DRG Validation findings.

Benefits

• Zelis maintains a transparent, fee-free recruitment process. All genuine offers originate from our Talent Acquisition team using the “@zelis.com” domain. We do not use WhatsApp or personal emails for recruitment. Forward any suspected fraud to [email protected] for prompt investigation. Thank you for staying vigilant.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: No Education Listed