Inpatient DRG Reviewer Job at Zelis (St. Petersburg)

Inpatient DRG Nursing Auditor

Join our team in Manila as Inpatient DRG Nursing Auditor. If you’re a registered...

Location

Philippines , Taguig City

Salary:

Not provided

Access Healthcare LLC

Expiration Date

Until further notice

Requirements

Good Comprehension skills
Strong attention to detail and communication skills
Curious and willing to ask relevant questions
Ability to understand client guidelines related to insurance advantage claims
Must be Philippine Registered Nurse with Active license
Must have an experience in clinical and audit in IP DRG

Job Responsibility

Conduct initial audit reviews to validate billed diagnoses and DRG code are supported by medical records
Record audit results and document finding notes based on policies using professional clinical resources
Perform provider appeals reviews and render decision to either uphold or overturn original finding
Review questionable encoder results, complex cases, and appeal reviews to facilitate referrals to clinical department as needed
Propose new audit concepts supported by your research and analysis
Define new audit concept criteria and test and validate new concepts developed by analytics team
Escalate facility issues per client guidance

New

DRG Clinical Dispute Reviewer

At Zelis, the DRG Clinical Dispute Reviewer role is responsible for the resoluti...

Location

United States , St. Petersburg; Plano; Boston; St. Louis; Atlanta

Salary:

95000.00 - 127000.00 USD / Year

Zelis

Expiration Date

Until further notice

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

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

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

Fulltime

New

Inpatient DRG Sr. Reviewer

As part of the Price Optimization division, this role is responsible for conduct...

Location

United States , St. Petersburg; Plano; Boston; St. Louis; Atlanta

Salary:

95000.00 - 120650.00 USD / Year

Zelis

Expiration Date

Until further notice

Requirements

Registered Nurse licensure preferred
Inpatient Coding Certification required (i.e., CCS, CIC, RHIA, RHIT)
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
Strong understanding of hospital coding and billing rules
Clinical and critical thinking skills to evaluate appropriate coding
Strong organization skills with attention to detail
Excellent communication skills both verbal and written, and skilled at developing and maintaining effective working relationships.
Demonstrated thought leadership and motivation skills, a self-starter with an ability to research and resolve issues

Job Responsibility

Perform comprehensive inpatient DRG validation Quality Assurance reviews to determine accuracy of the DRG billed, based on industry standard coding guidelines and the clinical evidence supplied by the provider
Implement and conduct quality assurance program to ensure accurate results to our clients
Manage assigned claims and claim report, adhering to client turnaround time, and department Standard Operating Procedures
Serve as the Subject Matter Expert on DRG validation to team members and other departments within the organization
Prepare and conduct training for new team members
Identify new DRG coding concepts to expand the DRG product
Meet and/or exceed all internal and department productivity and quality standards
Must remain current in all national coding guidelines including Official Coding Guidelines, AHA Coding Clinic and AMA CPT Assistant
Recommend efficiencies and process improvements to improve departmental procedures
Maintain awareness of and ensure adherence to Zelis standards regarding privacy

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

Fulltime

Client Partner

Location

India , Noida

Salary:

Not provided

Access Healthcare LLC

Expiration Date

Until further notice

Requirements

Minimum 1 to 4 years of experience in IPDRG medical coding -US Healthcare
Any Graduate
associate’s degree in health information management, Medical Coding, or a related field preferred
Specialization: Inpatient DRG
Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) certification required.

Job Responsibility

Assign DRG Codes: Accurately assign DRG codes to inpatient records using ICD-10- CM/PCS coding systems based on clinical documentation and physician notes. Ensure codes reflect the correct diagnosis, procedures, and the overall complexity of care.
Clinical Documentation Review: Review and analyze medical records to verify diagnoses, procedures, and treatments. Work with physicians and healthcare providers to clarify and improve clinical documentation when needed for proper coding.
DRG Assignment: Utilize the DRG methodology to ensure accurate and consistent DRG assignment based on the severity of illness (SOI) and risk of mortality (ROM), among other factors. Apply coding conventions and guidelines as per CMS (Centers for Medicare & Medicaid Services) and payer requirements.
Continuous Education: Keep up to date with coding guidelines, coding technology, and industry changes related to DRGs, including changes in ICD-10-CM/PCS, federal regulations, and insurance payer policies.
Billing Support: Work closely with the billing department to resolve coding issues and ensure that all claims are processed correctly and promptly for reimbursement. Ensure timely submission of all inpatient claims for accurate payment processing

Client Partner - Medical Coding - Inpatient Coding - IP/DRG

Start your career as a Client Partner for Inpatient Medical Coding - IP /DRG wit...

Location

India , Noida

Salary:

Not provided

Access Healthcare LLC

Expiration Date

Until further notice

Requirements

Graduates in life sciences with 1 - 4 years experience in Medical Coding
Candidates holding CCS/CIC with hospital coding experience are preferable
Good knowledge of Medical Coding and billing systems, medical terminologies, regulatory requirements, auditing concepts, and principles
Maintains a working knowledge of CPT-4, ICD-10-CM, and ICD-10-PCS coding principles, governmental regulations, UHDDS guidelines, AHA coding clinic updates, and third-party requirements regarding coding and documentation guidelines
Knowledge of Physician query process and ability to write physician queries in compliance with OIG and UHDDS regulations
Knowledge of MS-DRG, MDC, AP-DRG, APR-DRG with hands-on experience in handling MS-DRG
Knowledge of CC and MCC when used as a secondary diagnosis
Understanding and exposure to Clinical Documentation Improvement (CDI) program to work in tandem with MS-DRG
Hands-on experience in any Encoder tools specific to Hospital coding, such as 3M, Trucode, etc., is preferred
Maintains a high level of productivity and quality

Job Responsibility

Reviewing Inpatient and observation medical records, determining and assigning accurate diagnosis (ICD-10-CM) codes and Procedure codes (ICD-10-PCS and CPT) codes with appropriate modifiers in addition to reporting any deviations promptly
The coders will focus on undergoing certifications sponsored by AAPC and AHIMA as they mature with the process

What we offer

Access health care has now partnered with AAPC to handhold in-house certification training for coders and sponsor examinations

Fulltime

Hb coding integrity specialist - inpatient denials

Reviews coded health information records to evaluate the quality of staff coding...

Location

United States

Salary:

28.55 - 42.85 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Coding Specialist (CCS) certification issued by the American Health Information Management Association (AHIMA)
Health Information Administrator (RHIA) registration issued by the American Health Information Management Association (AHIMA)
Health Information Technician (RHIT) registration issued by the American Health Information Management Association (AHIMA)
Associate's Degree in Health Information Management or related field
Typically requires 5 years of experience in hospital coding for a large complex health care system, which includes hospital coding, denial review and/or coding quality review functions
Demonstrated leadership skills and abilities
Demonstrates knowledge of National Council on Compensation Insurance, Inc. (NCCI) edits, and local and national coverage decisions
Expert knowledge and experience in ICD-10-CM/PCS and CPT coding systems, G-codes, HCPCS codes, Current Procedural Terminology (CPT), modifiers, and Ambulatory Patient Categories (APC), MS-DRGs (Diagnosis related groups)
Advanced knowledge in Microsoft Applications, including but not limited to
Excel, Word, PowerPoint, Teams

Job Responsibility

Reviews coded health information records to evaluate the quality of staff coding and abstracting, verifying accuracy and appropriateness of assigned diagnostic and procedure codes, as well as other abstracted data, such as discharge disposition
Ensure accurate coding for outpatient, day surgery and inpatient records
Verifies all codes and sequencing for claims according to American Hospital Association (AHA) coding guidelines, CPT Assistant, AHA Coding Clinic and national and local coverage decisions
Works collaboratively with coding leadership per their direction in reviewing records with focused diagnosis and procedure codes, including specific APCs, DRGs and OIG work plan targets to assure compliance in all areas of coding, which may give visibility into documentation that is driving codes
Works collaboratively with coding leadership to identify focused prospective records that need to be reviewed
Identifies coder education opportunities, team trends, and consideration of topics to mandate for second level account review, before the account is final coded
Reviews encounters flagged for second level review, including but not limited to
hospital acquired conditions (HACs), complications and other identified records such as core measures or trends as identified by coding leadership
Perform review of coded encounter for appropriate risk-adjustment, including accurate severity and risk of mortality assignment
Responsible for coding participation in the Clinical Documentation Improvement and Hospital Coding alignment process

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Opportunity for annual increases based on performance
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions

Fulltime

New

Coder IV facility hospital based

Location

United States

Salary:

30.15 - 45.25 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Minimum of five years' of coding experience in an academic medical center or an equivalent combination of coding experience and education with demonstrated competency of knowledge base
Coding QA background or similar experience preferred
Satisfactory completion of college level courses in anatomy, physiology and medical terminology preferred
EPIC health information system experience preferred
Coding certification CCA, CIC, CPC-H, CPC, CCS, RHIT, or RHIA required
Ability to concentrate for extended periods
Knowledge of medical terminology and basic anatomy, physiology, pathophysiology, and pharmacology with ability to apply knowledge to the coding process
Demonstrates skill in coding classification systems, diagnosis, procedure selection, and sequencing guidelines
Knowledge of APC prospective payment system
Demonstrates competence in coding and correct extrapolation of official coding and select billing guidelines to specific coding situations

Job Responsibility

Ensures the timely and accurate coding and completion of patient accounts within established departmental accuracy and productivity standards
Applies correct ICD CM/PCS (Inpatient) and ICD CM/CPT codes (Outpatient) guidelines meeting departmental policy regarding compliant methods, timeframes, use of applications and productivity
Assists in demonstrating medical necessity for procedures performed by ensuring that all documented disease processes are coded
Demonstrates proficiency in utilizing official coding books as well as the electronic medical record, computer assisted coding/encoding software, and clinical documentation information systems to facilitate code assignment
Reviews facility charges as provided and edits where necessary to ensure charges are compliant and substantiated by provider documentation
May require frequent and close collaboration with multiple areas of the organization including providers, Professional Coding, and Finance for audit and problem-solving activities
Demonstrates full understanding and is compliant with correct coding initiative guidelines, regulatory requirements regarding coding of medical information including but not limited to external regulatory agencies such as Quality Improvement Organizations (QIOs), the Centers for Medicare & Medicaid Services (CMS) and other payers, and the Joint Commission
Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines
Queries physician when existing documentation is unclear or ambiguous following AHIMA guidelines and established policy
Brings identified concerns to Manager Coding for resolution

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

Hb coding integrity specialist - inpatient denials

Reviews coded health information records to evaluate the quality of staff coding...

Location

United States

Salary:

28.55 - 42.85 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Coding Specialist (CCS) certification issued by the American Health Information Management Association (AHIMA), or Health Information Administrator (RHIA) registration issued by AHIMA, or Health Information Technician (RHIT) registration issued by AHIMA
Associate's Degree in Health Information Management or related field
Typically requires 5 years of experience in hospital coding for a large complex health care system, which includes hospital coding, denial review and/or coding quality review functions
Demonstrated leadership skills and abilities
Expert knowledge and experience in ICD-10-CM/PCS and CPT coding systems, G-codes, HCPCS codes, Current Procedural Terminology (CPT), modifiers, and Ambulatory Patient Categories (APC), MS-DRGs (Diagnosis related groups)
Advanced knowledge in Microsoft Applications, including but not limited to
Excel, Word, PowerPoint, Teams
Advanced knowledge and understanding of anatomy and physiology, medical terminology, pathophysiology (disease process, surgical terminology and pharmacology.)
Advanced knowledge of pharmacology indications for drug usage and related adverse reactions
Expert knowledge of coding work flow and optimization of technology including how to navigate in the electronic health information record and in health information management and billing systems

Job Responsibility

Reviews coded health information records to evaluate the quality of staff coding and abstracting, verifying accuracy and appropriateness of assigned diagnostic and procedure codes, as well as other abstracted data, such as discharge disposition
Ensure accurate coding for outpatient, day surgery and inpatient records
Verifies all codes and sequencing for claims according to American Hospital Association (AHA) coding guidelines, CPT Assistant, AHA Coding Clinic and national and local coverage decisions
Works collaboratively with coding leadership per their direction in reviewing records with focused diagnosis and procedure codes, including specific APCs, DRGs and OIG work plan targets to assure compliance in all areas of coding
Works collaboratively with coding leadership to identify focused prospective records that need to be reviewed
Identifies coder education opportunities, team trends, and consideration of topics to mandate for second level account review, before the account is final coded
Reviews encounters flagged for second level review, including but not limited to
hospital acquired conditions (HACs), complications and other identified records such as core measures or trends as identified by coding leadership
Perform review of coded encounter for appropriate risk-adjustment, including accurate severity and risk of mortality assignment
Responsible for coding participation in the Clinical Documentation Improvement and Hospital Coding alignment process

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

Inpatient DRG Reviewer

Zelis

Location:
United States , St. Petersburg ▼
Plano
Boston
St. Louis
Atlanta

Category:
Health and Beauty

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Additional Information:

Job Posted:
February 20, 2026

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