DRG Clinical Dispute Reviewer

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.

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

At Zelis, the DRG Clinical Dispute Reviewer role is responsible for the resolution of facility and provider disputes as they relate to DRG validation. They will be responsible for reviewing facility inpatient and outpatient claims for Health Plans and TPA's to ensure adherence to proper coding and billing, analyzing inpatient DRG claims based on industry standard inpatient coding guidelines, and supporting the Office of the Chief Medical Officer in managing disputes related to clinical claim reviews.

This position is a production-based role with production and quality metric goals.

What you'll do:

• Review provider disputes for
  
  DRGCoding and Clinical
  
  Validation(MS and APR)

• Reviewandsubmitexplanation of dispute rationale back to providers based on dispute findings within the designatedtimeframeto ensure client turnaround times are met.

• Accountable for daily management ofclaim dispute volume, adhering to client turnaround time, and department Standard Operating Procedures

• Serve assubject matter expert forthe
  
  Expert Claim Review Teamonday -to-dayactivitiesincludingtroubleshooting and review fordata accuracy.

• Serve as a subject matter expert for content andbill reviews and provide support whereneededforinquiriesandresearch requests.

• Create andpresenteducation to Expert Claim Review Teamsand otherdepartmentsdispute findings.

• Researchandanalysisof content forDRGreviews.

• Use of strong coding and industry knowledge to create andmaintainclaimreview content, including but not limited to DRG Reviewer Rationales, DRG Clinical Validation Policies and Dispute Rationales

• Perform regulatory research from multiple sourcesto keep abreast of compliance enhancements andadditionalbill review opportunities.

• Support for client facing teams as needed relating to client inquiries related to provider disputes.

• Utilize the most up-to-date approved Zelis medical coding sources forclaimreviewmaintenance.

• Communicate and partner with CMO and members of Expert Claim Review Product and Operations teamsregardingimportant issuesand trends.

• Ensure adherence to quality assurance guidelines.

• Monitor, research, and summarize trends, coding practices, and regulatory changes.

• Actively contribute new ideasand support ad hoc projects, including time-sensitive requests.

• Ensure adherence to quality assurance guidelines.

• Maintain awareness of and ensure adherence to ZELIS standardsregardingprivacy.

What you'll bring to Zelis:

• 5+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferred

• Current, active
  
  Inpatient Coding Certification required (ie. CCS,CIC,RHIA, RHIT,CPC or equivalent credentialing).

• Registered Nurse licensurepreferred

• Bachelor's Degree Preferred in business,healthcare,or technology preferred.

• Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers

• Experience and working knowledge of Health Insurance, Medicareguidelinesand various healthcareprograms

• Understanding of hospital coding and billing rules

• Clinical skills to evaluate appropriate Medical Record Coding

• Experience performing regulatory research from multiple sources, formulating an opinion,and presenting findings inanorganized,concise manner.

• Background and/or understanding of the healthcare industry.

• Knowledge of National Medicare and Medicaid regulations.

• Knowledge of payer reimbursement policies.

• Creative problem-solving skills,leveraginginsightsand input from other parts of an organization.

• Consistentlydemonstrateabilityto act and react swiftly to continuous challenges and changes.

• Excellent analytical skills with data and analytics related solutions.

• Excellent communication skills.

• Strong organization and project/process management skills.

• Strong initiative, self-directed and self-motivation.

• Good negotiation, problem solving,planning and decision-making skills.

• Ability to manage projects simultaneously and achieve goals.

• Excellent follow through, attention to detail, and time management skills.

Please note at this time we are unable to proceed with candidates who…