KEY 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.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 reviewDocument all aspect of audits including uploading all provider communications, clinical rationale, and/or financial researchIdentify new DRG coding concepts to expand the DRG product.Manage assigned claims and claim report, adhering to client turnaround time, and department Standard Operating ProceduresMeet and/or exceed all internal and department productivity and quality standardsRecommend new methods to improve departmental proceduresAchieve and maintain personal production and savings quotaMaintain awareness of and ensure adherence to Zelis standards regarding privacy

TECHNICAL SKILLS/ KNOWLEDGE:

Recommended: Nursing degree or equivalentInpatient Coding Certification required (i.e. CCS, CIC, RHIA, RHIT)3-5 years of experience in Inpatient coding3–5 years of experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs4+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferredSolid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providersUnderstanding of hospital coding and billing rulesClinical skills to evaluate appropriate Medical Record CodingExperience conducting root cause analysis and identifying solutionsStrong organization skills with attention to detailOutstanding verbal and written communication skill

INDEPENDENCE/ ACCOUNTABILITY:

Regularly reviews goals and objectives with supervisorMust have professional manner and respect the confidentiality of administrative matters and filesAbility to manage and prioritize multiple tasksAbility to work under pressure and meet deadlinesAbility to follow detailed instructions on assignments

COMMUNICATION SKILLS:

Must work well with othersCommunicates accurately, honestly, and effectively, both in oral and written form, practices active listeningClearly conveys information and ideas through a variety of media to individuals and groups in a manner that engages the audience and helps them understand the information

Zelis is modernizing the healthcare financial experience 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 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts – driving real, measurable results for clients.

Commitment to Diversity, Equity, Inclusion, and Belonging 
At Zelis, we champion diversity, equity, inclusion, and belonging in all aspects of our operations. We embrace the power of diversity and create an environment where people can bring their authentic and best selves to work. We know that a sense of belonging is key not only to your success at Zelis, but also to your ability to bring your best each day.

Equal Employment Opportunity  
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 encourage members of traditionally underrepresented communities to apply, even if you do not believe you 100% fit the qualifications of the position, including women, LGBTQIA people, people of color, and people with disabilities.  

Accessibility Support 

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.  

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