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Zelis Logo Zelis · -

Inpatient DRG Sr. Reviewer

United States, St. Petersburg 95000.00 - 120650.00 USD / Year · Job Posted February 20, 2026
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Job Description

As part of the Price Optimization division, this role is responsible for conducting post-service, pre-payment and post pay comprehensive inpatient DRG Quality Assurance reviews in an effort to increase the savings achieved for Zelis clients. Conduct reviews on inpatient DRG claims as they compare with medical records utilizing ICD-10 Official Coding Guidelines, AHA Coding Clinic evidence based clinical criteria and client specific coverage policies.

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

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

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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