Inpatient DRG Reviewer-3

Zelis•US NC Remote, NC

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 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 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.

Requirements

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

Responsibilities

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