DRG Dispute Reviewer-2

About Us

Zelis is modernizing the healthcare financial experience in the United States (U.S.) 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.

Why We Do What We Do

In the U.S., consumers, payers, and providers face significant challenges throughout the healthcare financial journey. Zelis helps streamline the process by offering solutions that improve transparency, efficiency, and communication among all parties involved. By addressing the obstacles that patients face in accessing care, navigating the intricacies of insurance claims, and the logistical challenges healthcare providers encounter with processing payments, Zelis aims to create a more seamless and effective healthcare financial system.

Zelis India plays a crucial role in this mission by supporting various initiatives that enhance the healthcare financial experience. The local team contributes to the development and implementation of innovative solutions, ensuring that technology and processes are optimized for efficiency and effectiveness. Beyond operational expertise, Zelis India cultivates a collaborative work culture, leadership development, and global exposure, creating a dynamic environment for professional growth. With hybrid work flexibility, comprehensive healthcare benefits, financial wellness programs, and cultural celebrations, we foster a holistic workplace experience. Additionally, the team plays a vital role in maintaining high standards of service delivery and contributes to Zelis’ award-winning culture.

Position Overview

At Zelis, the DRG Dispute Reviewer role is responsible for the resolution of facility and provider disputes as they relate to DRG validation, itemized bill review, and/or clinical claim review Expert Claim Review. 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 guidelines as it relates to the Itemized Bill Review product, 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 will also be responsible for being a resource for the entire organization regarding DRG claims. This is a production-based role with production and quality metric goals.

Key responsibilities:

• Review provider disputes for DRG Coding and Clinical Validation (MS and APR), 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 subject matter expert for the Expert Claim Review Team on day-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 bill review.

• Use of strong coding and industry knowledge to create and maintain bill review content, including but not limited to DRG Reviewer Rationales, DRG Clinical Validation Policies, CCR Review Guidelines and Templates, 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 bill review maintenance.

• Communicate and partner with CMO and members of Expert Claim Review Product and Operations teams regarding critical issues and trends.

• Ensure adherence to quality assurance guidelines.

• Monitor, research, and summarize trends, coding practices, and regulatory changes.

• Actively contribute innovative ideas and support ad hoc projects, including time-sensitive requests.

• Ensure adherence to quality assurance guidelines.

• Maintain awareness of and ensure adherence to ZELIS standards regarding privacy.

Skills, Knowledge, and experience:

• 5+ 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

• 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 and Medicaid regulations.

• Knowledge of payer reimbursement policies.

• Creative problem-solving skills, leveraging insights and input from other parts of an organization.

• Consistently demonstrate ability to act and react swiftly to continuous challenges and changes.

• Excellent analytical skills with data and analytics related solutions.

• Excellent communication skills.

• Strong organization and project/process management skills.

• Strong initiative, self-directed and self-motivation.

• Good negotiation, problem solving, planning and decision-making skills.

• Ability to manage projects simultaneously and achieve goals.

• Excellent follow through, attention to detail, and time management skills.

education:

• Current, active Inpatient Coding Certification required (i.e., CCS, CIC, RHIA, RHIT, CPC or equivalent credentialing).

• Registered Nurse licensure preferred

• Bachelor’s degree in business, healthcare, or technology preferred.

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 required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.

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 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.

Accessibility Support

We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability and require reasonable accommodation with any part of the application and/or interview process, please email talentacquisition@zelis.com.