Position Overview:

The DRG Validation Nurse Reviewer will be primarily 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 possible savings for clients.

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.
• 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

Skills, Knowledge, and Experience:

• Registered Nurse licensure required
• Inpatient Coding Certification required (i.e. CCS, CIC, RHIA, RHIT)
• 3-5 years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims required
• 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 conducting root cause analysis and identifying solutions
• Strong organization skills with attention to detail
• Outstanding verbal and written communication skills

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As a leading payments company in healthcare, we guide, price, explain, and pay for care on behalf of insurers and their members. We're Zelis in our pursuit to align the interests of payers, providers, and consumers to deliver a better financial experience and more affordable, transparent care for all. We partner with more than 700 payers, including the top-5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, over 4 million providers, and 100 million members, enabling the healthcare industry to pay for care, with care. Zelis brings adaptive technology, a deeply ingrained service culture, and a comprehensive navigation through adjudication and payment platform to manage the complete payment process.

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.

Equal Employment Opportunity
Zelis is proud to be an equal opportunity employer. All 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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