DRG Clinical Dispute Reviewer

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At Zelis, we Get Stuff Done. So, let’s get to it!

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.

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.

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.

• Review provider disputes for DRG Coding and Clinical Validation (MS and APR)
• Review and submit explanation of dispute rationale back to providers based on dispute findings within the designated timeframe to ensure client turnaround times are met.
• Accountable for daily management of claim dispute volume, adhering to client turnaround time, and department Standard Operating Procedures.
• Serve as a subject matter expert for the Expert Claim Review Team Monday-to-day activities including troubleshooting and review for data accuracy.
• Serve as a subject matter expert for content and bill reviews and provide support where needed for inquiries and research requests.
• Create and present education to Expert Claim Review Teams and other departments dispute findings.
• Research and analysis of content for DRG reviews.
• Use strong coding and industry knowledge to create and maintain claim review content, including but not limited to DRG Reviewer Rationales, DRG Clinical Validation Policies and Dispute Rationales.
• Perform regulatory research from multiple sources to keep abreast of compliance enhancements and additional bill 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 for claim review maintenance.
• Communicate and partner with CMO and members of Expert Claim Review Product and Operations teams regarding important issues and trends.
• Ensure adherence to quality assurance guidelines.
• Monitor, research, and summarize trends, coding practices, and regulatory changes.
• Actively contribute new ideas and support ad hoc projects, including time-sensitive requests.
• Maintain awareness of and ensure adherence to ZELIS standards regarding privacy.

• 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 licensure preferred.
• 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, Medicare guidelines and various healthcare programs.
• Understanding of hospital coding and billing rules.
• Clinical skills to evaluate appropriate Medical Record Coding.
• Experience performing regulatory research from…