DRG Clinical Dispute Reviewer Job at Zelis (St. Petersburg)

Job Description

At Zelis, the DRG Clinical Dispute Reviewer role is responsible for the resolution of facility and provider disputes as they relate to DRG validation. 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, 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 is a production-based role with production and quality metric goals.

Job Responsibility

Review provider disputes for DRG Coding and Clinical Validation (MS and APR)
Review 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 DRG reviews
Use of strong coding and industry knowledge to create and maintain claim review content, including but not limited to DRG Reviewer Rationales, DRG Clinical Validation Policies 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 claim review maintenance
Communicate and partner with CMO and members of 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

Requirements

5+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims
Current, active Inpatient Coding Certification required (ie. CCS, CIC,RHIA, RHIT, CPC or equivalent credentialing)
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

Nice to have

Registered Nurse licensure
Bachelor’s Degree Preferred in business, healthcare, or technology

What we offer

401k plan with employer match
flexible paid time off
holidays
parental leaves
life and disability insurance
health benefits including medical, dental, vision, and prescription drug coverage

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DRG Clinical Dispute Reviewer

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