Responsibilities

• Serve as subject matter expert for the Ideation Team on day-to-day activities including troubleshooting and review for data accuracy
• Review provider disputes for DRG and IBR and submit explanation of dispute rationale back to providers based on dispute findings within the designated timeframe to ensure client turnaround times are met
• 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 Operations team and CMO along with potentially other departments on new and updated concepts, review guidelines, and dispute findings
• Research and analysis of content for Itemized Bill Review and DRG Validation
• 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, and Dispute Rationales
• Perform regulatory research from multiple sources to keep abreast of compliance enhancements and additional bill review opportunities.
• Analysis of data to assess impact for content related issues or defects. Contribute to product alerts and partner with Product Management on notifications
• Utilize the most up-to-date approved Zelis medical coding sources for bill review maintenance and development
• Partner with other areas to assess and communicate impact to the business for additions, changes, or updates as it relates to content and bill review updates

Requirements

• Current, active CIC or CCS or equivalent credentialing is required
• RN or LPN with coding certification, or certified coder, or registered health information technician (RHIA/RHIT) with at least 6-8 years of experience
• Experience with MS-DRG/APR-DRG coding and compliance required
• Experience performing regulatory research from multiple sources, formulating an opinion, and presenting findings in an organized, concise manner
• 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
• Ability to leverage reporting tools to research claim data, trending and analysis for concept ideation processes
• Understanding of JIRA/Confluence recommended
• Strong organization and project/process management skills

Benefits

• Zelis full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees’ health, well-being, and financial protection.
• The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage.