Clinical Dispute Reviewer
Clinical Dispute Reviewer
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Job Description
At Zelis we Get Stuff Done. So lets 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 youve learned along the way. You are more than just your resume; you are a reflection of your achievements the knowledge youve gained and the personal interests that shape who you are.
Position Overview
At Zelis the Clinical Dispute Analyst 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 TPAs 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 IBR and CCR claims. This is a production-based role with production and quality metric goals.
What youll do:
Review provider disputes for DRG Coding and Clinical Validation (MS and APR) Itemized Bill Review (IBR) and Clinical Chart Review (CCR) and submit explanation of dispute rationale back to providers based on dispute findings within the designated timeframe to ensure client turnaround times are met.
Accountable for daily management of claim dispute volume adhering to client turnaround time and department Standard Operating Procedures
Serve as subject matter expert for the Expert Claim Review Team on day-to-day activities including troubleshooting and review for data accuracy.
Serve as a subject matter expert for content and bill reviews and provide support where needed for inquiries and research requests.
Create and present education to Expert Claim Review Teams and other departments dispute findings.
Research and analysis of content for bill review.
Use of strong coding and industry knowledge to create and maintain bill review content including but not limited to DRG Reviewer Rationales DRG Clinical Validation Policies CCR Review Guidelines and Templates and Dispute Rationales
Perform regulatory research from multiple sources to keep abreast of compliance enhancements and additional bill review opportunities.
Support for client facing teams as needed relating to client inquiries related to provider disputes.
Utilize the most up-to-date approved Zelis medical coding sources for bill review maintenance.
Communicate and partner with CMO and members of Expert Claim Review Product and Operations teams regarding critical issues and trends.
Ensure adherence to quality assurance guidelines.
Monitor research and summarize trends coding practices and regulatory changes.
Actively contribute innovative ideas and support ad hoc projects including time-sensitive requests.
Ensure adherence to quality assurance guidelines.
Maintain awareness of and ensure adherence to ZELIS standards regarding privacy.
What youll bring to Zelis:
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
Understanding of hospital coding and billing rules
Clinical skills to evaluate appropriate Medical Record Coding
Experience performing regulatory research from multiple sources formulating an opinion and presenting findings in an organized concise manner.
Background and/or understanding of the healthcare industry.
Knowledge of National Medicare and Medicaid regulations.
Knowledge of payer reimbursement policies.
Creative problem-solving skills leveraging insights and input from other parts of an organization.
Consistently demonstrate ability to act and react swiftly to continuous challenges and changes.
Excellent analytical skills with data and analytics related solutions.
Excellent communication skills.
Strong organization and project/process management skills.
Strong initiative self-directed and self-motivation.
Good negotiation problem solving planning and decision-making skills.
Ability to manage projects simultaneously and achieve goals.
Excellent follow through attention to detail and time management skills.
Current active Inpatient Coding Certification required (i.e. CCS CIC RHIA RHIT CPC or equivalent credentialing).
Registered Nurse licensure preferred
Bachelors degree in business healthcare or technology preferred.
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 employees work locations are based on the needs of the position and determined by the Leadership -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 dont 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 .
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.
Employment Type
Full-Time
