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At Zelis, we Get Stuff Done. So, let's get to it! A Little About Us Zelis is modernizing the healthcare financial experience 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. A Little About You You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are. Position Overview The Manager, DRG Validation of the Expert Claims Review (ECR) department is responsible for daily operations and team management of the DRG product. The Manager, DRG Validation will be primarily responsible for the oversight of DRG validation reviews to ensure accurate and compliant coding based on industry standard inpatient coding guidelines and rules, evidence based clinical criteria, and policy exclusions. Focus will be on analyzing and executing on current business and new client implementations, establishing, and monitoring team performance metrics and ensuring client needs are met.

What you'll do: Oversee the DRG validation process including management of claim assignment and queues, adherence to client turnaround time and department procedures

Serve as the Subject Matter Expert on DRG validation to team members and other departments within the organization

Lead and manage a team of coding professionals by providing guidance, training, and support to encourage a positive and collaborative team culture

Monitor key performance indicators to track team productivity and accuracy, client and concept trends and implement improvement strategies

Implement and conduct quality assurance program to ensure accurate results to our clients

Collaborate with Product, IT, Implementation and Sales teams to drive growth initiatives and outcomes

Assist in dispute process and defense of denials as necessary

Must remain current in all national coding guidelines including Official Coding Guidelines, AHA Coding Clinic and AMA CPT Assistant

Participate in client facing meetings as necessary

Identify new DRG coding concepts to drive growth opportunities.

Recommend efficiencies and process improvements to improve departmental procedures

Maintain awareness of and ensure adherence to Zelis standards regarding privacy

What you'll bring to Zelis: Registered Nurse licensure required

Inpatient Coding Certification required (i.e., CCS, CIC, RHIA, RHIT)

5 - 7 years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims required

Supervisory experience preferred

Solid understanding of audit techniques and identification of revenue opportunities

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

Experience conducting root cause analysis and identifying solutions

Strong organization skills with attention to detail

Outstanding verbal and written communication skills

Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future. Location and Workplace Flexibility We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies. 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.

We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all. Accessibility Support We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email TalentAcquisition@zelis.com.

Disclaimer We are an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, national origin, disability status, protected veteran status, or any other characteristic protected by law. 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 from time to time.