DRG Clinical Dispute Reviewer

DRG Clinical Dispute Reviewer

Join to apply for the DRG Clinical Dispute Reviewer role at Zelis
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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. The reviewer will examine facility inpatient and outpatient claims for Health Plans and TPAs to ensure adherence to proper coding and billing, analyze inpatient DRG claims based on industry-standard inpatient coding guidelines, and support the Office of the Chief Medical Officer in managing disputes related to clinical claim reviews.

This production-based role includes meeting production and quality metric goals.

• Review provider disputes for DRG coding and clinical validation (MS and APR).
• Review and submit explanations of dispute rationale back to providers within the designated timeframe to ensure client turnaround times are met.
• Accountable for daily management of claim dispute volume, adhering to client turnaround times and department SOPs.
• Serve as a subject matter expert for the Expert Claim Review Team’s day‑to‑day activities, including troubleshooting and review for data accuracy.
• Provide subject‑matter expertise for content and bill reviews and support inquiries and research requests.
• Create and present education to Expert Claim Review Teams and other departments on dispute findings.
• Research and analyze content for DRG reviews.
• Use strong coding and industry knowledge to create and maintain claim review content, including DRG reviewer rationales, clinical validation policies, and dispute rationales.
• Perform regulatory research from multiple sources to stay abreast of compliance enhancements and additional bill review opportunities.
• Support client‑facing teams as needed regarding provider disputes.
• Utilize the most up‑to‑date approved Zelis medical coding sources for claim review maintenance.
• Communicate and partner with the CMO and members of the 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 (e.g., CCS, CIC, RHIA, RHIT, CPC or equivalent).
• Registered Nurse licensure preferred.
• Bachelor’s Degree preferred in business, healthcare, or technology.
• Solid understanding of audit techniques, revenue opportunity identification, 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 multiple sources, formulating an opinion, and presenting findings in an organized, concise manner.
• Background and/or understanding of the healthcare industry.
• Knowledge of National Medicare…