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DRG Clinical Dispute Reviewer

United States, St. Petersburg 95000.00 - 127000.00 USD / Year · Job Posted February 20, 2026
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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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