Sr. Manager, DRG Validation

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.

At Zelis, AI is woven into the fabric of how we work. Every associate is expected - and empowered - to partner with AI to challenge the status quo, accelerate innovation, and amplify their impact. This is a place for builders with a growth mindset who act with agility, embrace change, and use modern technology to shape smarter solutions, exceptional experiences, and the future of our industry for our clients, customers, and our culture.

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

What You'll Do:

• Manage multiple teams or a large team with diverse technical responsibilities.
• Define long-term vision and strategic priorities for Clinical Review across the organization.
• Drive enterprise-wide initiatives to enhance compliance, quality assurance, and operational efficiency.
• Collaborate with executive leadership to align Clinical Review objectives with corporate strategy.
• Lead policy development and ensure adherence to national and international regulatory standards.
• Oversee large-scale audits, risk assessments, and accreditation processes.
• Represent the organization in external professional conferences, regulatory forums, and industry partnerships.
• Champion innovation by evaluating emerging technologies and integrating AI-driven solutions into review processes.
• Develop succession plans and leadership pipelines to sustain organizational growth and expertise.
• Provide training, support, and development opportunities to team members to ensure high performance and engagement.
• Conduct regular performance reviews, provide feedback, and identify opportunities for professional development.

What You'll Bring to Zelis:

• Typically has Bach. +12 yrs.; Masters +8 yrs. Attends company training and regional training in area of expertise. Presents own work to members of department and external consultants and external professional conferences, Collaborates externally, Hosts external guests, visitors and consultants
• Requires proficiency using AI tools skillfully with an understanding of how to develop/create intelligent prompts and/or agents.
• Experience leading multiple teams or large-scale projects.
• Strong strategic thinking and execution capabilities.
• Ability to influence cross-functional stakeholders and drive alignment.
• Advanced leadership and coaching skills.
• Advanced knowledge of healthcare regulations, guidelines, and best practices related to clinical reviews.
• Certification in clinical review or a related field is preferred (e.g., Certified Professional in Healthcare Quality (CPHQ)).
• Strong financial and operational management skills.
• Ability to drive strategic initiatives and influence executive stakeholders.
• Strong leadership and team management skills, with the ability to motivate and inspire others.

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

Zelis is headquartered in the U.S., with multiple locations across the country and in Hyderabad, India. Check out our locations to learn more about our offices. All employee work locations are based on the needs of the position and are determined by the Leadership team. In-office work and activities vary based on work and team objectives in accordance with Company policies.

While location expectations vary by role, candidates within approximately 50 miles of a U.S. office are generally preferred to support collaboration when needed. Our hybrid approach is flexible, and in-office presence is guided by team and business needs rather than a fixed weekly schedule.

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

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.