Position Overview

At Zelis, the DRG Dispute Reviewer role is responsible for the resolution of facility and provider disputes as they relate to DRG validation, itemized bill review, and/or clinical claim review Expert Claim Review. 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 guidelines as it relates to the Itemized Bill Review product, 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 will also be responsible for being a resource for the entire organization regarding DRG claims. This is a production-based role with production and quality metric goals.

Key responsibilities:

Review provider disputes for DRG Coding and Clinical Validation (MS and APR), and submit explanation of dispute ra...