Inpatient DRG Reviewer
Listed on 2026-02-01
-
Healthcare
Healthcare Administration
Overview
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 OverviewAs 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.
- 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
(If this job is in fact in your jurisdiction, then you may be using a Proxy or VPN to access this site, and to progress further, you should change your connectivity to another mobile device or PC).