Job Description

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.

At Zelis, AI is woven into the fabric of how we work. Every associate is expected - and empowered - to partner with AI to challenge the status quo, accelerate innovation, and amplify their impact. This is a place for builders with a growth mindset who act with agility, embrace change, and use modern technology to shape smarter solutions, exceptional experiences, and the future of our industry for our clients, customers, and our culture.

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.

As 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.

What you will do:

• 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 ‘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 aspects 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

What you will bring:

Required

• RN or LVN required

• Inpatient Coding Certification required (CCS, CIC) within 4 – 6 months of hire date

• 1 -3 years reviewing and or auditing ICD-10 CM, MS-DRG and APPR-DRG claims preferred

• Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs

• Experience performing readmission reviews, including evaluating relatedness, preventability, and compliance with readmission policies

• 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

Work environment

• A standard work week exists but with the understanding that additional time/effort outside of the usual parameters can/will occur based upon the overall needs of our clients and business unit.

• A standard business environment exists with moderate noise levels.

• Ability to lift and move approximately thirty (30) pounds on a non-routine basis.

• Ability to sit for extended periods of time. 

Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future.

Location and Workplace Flexibility

Zelis is headquartered in the U.S., with multiple locations across the country and in Hyderabad, India. Check out our locations to learn more about our offices. All employee work locations are based on the needs of the position and are determined by the Leadership team. In-office work and activities vary based on work and team objectives in accordance with Company policies.

While location expectations vary by role, candidates within approximately 50 miles of a U.S. office are generally preferred to support collaboration when needed. Our hybrid approach is flexible, and in-office presence is guided by team and business needs rather than a fixed weekly schedule.

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.

We welcome applicants from all backgrounds and encourage you to apply even if you don’t meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all.

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

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.