What are the responsibilities and job description for the Inpatient DRG Reviewer position at Zelis?
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.
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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 review
- Document all aspect of audits including uploading all provider communications, clinical rationale, and/or financial research
- Identify new DRG coding concepts to expand the DRG product.
- Manage assigned claims and claim report, adhering to client turnaround time, and department Standard Operating Procedures
- Meet and/or exceed all internal and department productivity and quality standards
- Recommend new methods to improve departmental procedures
- Achieve and maintain personal production and savings quota
- Maintain awareness of and ensure adherence to Zelis standards regarding privacy
TECHNICAL SKILLS/ KNOWLEDGE:
- Recommended: Nursing degree or equivalent
- Inpatient Coding Certification required (i.e. CCS, CIC, RHIA, RHIT)
- 3-5 years of experience in Inpatient coding
- 3–5 years of experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs
- 4 years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferred
- Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers
- Understanding of hospital coding and billing rules
- Clinical skills to evaluate appropriate Medical Record Coding
- Experience conducting root cause analysis and identifying solutions
- Strong organization skills with attention to detail
- Outstanding verbal and written communication skill
INDEPENDENCE/ ACCOUNTABILITY:
- Regularly reviews goals and objectives with supervisor
- Must have professional manner and respect the confidentiality of administrative matters and files
- Ability to manage and prioritize multiple tasks
- Ability to work under pressure and meet deadlines
- Ability to follow detailed instructions on assignments
COMMUNICATION SKILLS:
- Must work well with others
- Communicates accurately, honestly, and effectively, both in oral and written form, practices active listening
- Clearly 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.
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.
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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