Job Overview
Location
US NC Remote
Job Type
Full-time
Category
Software Engineering
Date Posted
June 6, 2026
Full Job Description
đź“‹ Description
- • Conduct comprehensive inpatient DRG validation reviews to determine accuracy of billed DRGs using medical records, including physician notes, lab tests, and imaging, aligned with ICD-10 Official Coding Guidelines, AHA Coding Clinic, and client-specific policies.
- • Perform readmission reviews to evaluate prior and current admissions for preventability, relatedness, and compliance with established readmission policies.
- • Analyze clinical evidence to determine and record appropriate revised Diagnosis Codes, Procedure Codes, and Discharge Status Codes for inpatient claims.
- • Regroup claims using provided software based on revised codes to calculate the new DRG and compare it against the originally billed DRG.
- • Draft clear, customer-facing rationale statements that explain discrepancies between billed and revised DRGs, supported by clinical evidence and coding guidelines.
- • Document all audit findings, including uploading provider communications, clinical justifications, and financial research into designated systems.
- • Identify emerging DRG coding concepts and contribute insights to expand the organization’s DRG product offerings.
- • Manage assigned claim inventory in alignment with client turnaround time requirements and department Standard Operating Procedures.
- • Meet or exceed internal productivity and quality standards for claim reviews, including accuracy, timeliness, and documentation completeness.
- • Achieve and maintain personal production and savings quotas tied to client cost optimization goals.
- • Maintain strict adherence to Zelis privacy standards and healthcare data confidentiality protocols.
- • Recommend process improvements to enhance departmental efficiency, accuracy, and scalability of DRG review operations.
- • Collaborate with cross-functional teams to ensure alignment between clinical coding decisions and financial outcomes for payers and providers.
- • Stay current with evolving Medicare guidelines, health insurance policies, and industry best practices in inpatient coding and reimbursement.
- • Work within a hybrid environment where in-office presence is guided by team and business needs, with no fixed weekly schedule required.
- • Operate in a standard business environment with moderate noise levels, requiring extended periods of sitting and occasional non-routine lifting of up to 30 pounds.
🎯 Requirements
- • RN or LVN license required
- • Inpatient Coding Certification (CCS or CIC) required within 4–6 months of hire
- • 1–3 years of experience reviewing or auditing ICD-10-CM, MS-DRG, and APPR-DRG claims preferred
- • Experience performing readmission reviews, including evaluating relatedness and preventability
- • Working knowledge of Health Insurance, Medicare guidelines, and healthcare programs
- • Clinical skills to evaluate appropriate medical record coding and billing rules
🏖️ Benefits
- • Opportunity to work with AI tools to enhance decision-making and innovation in healthcare financial operations
- • Hybrid work model with flexible in-office requirements based on team and business needs
- • Employment with a leading healthcare financial technology company serving top national health plans
- • Inclusion in an equal opportunity employer culture that values diverse perspectives and experiences
Skills & Technologies
Remote
About Zelis Healthcare LLC
Zelis Healthcare LLC provides cloud-based healthcare financial technology that streamlines payments, price transparency, and network management for health plans, providers, and consumers. Its platform automates claims processing, re-pricing, electronic payments, and member billing, integrating data analytics to reduce administrative costs and improve payment accuracy across the healthcare revenue cycle.
Get more remote jobs like this
Subscribe to the weekly newsletter for similar remote roles and curated hiring updates.
Newsletter
Weekly remote jobs and featured talent.
No spam. Only curated remote roles and product updates. You can unsubscribe anytime.
