ESSENTIAL FUNCTIONS:

• Research medical records for complex and multi-specialty provider claims with the objective of determining appropriately coded billed services when compared to the Zelis Claim Edits Product and to maintain the editing product integrity
• Review and resolve complex inquiries up to identified targeted edit savings on corrected claims, disputes and edit validation as a team resource to retain savings.
• Identify any update information on the corrected claims, disputes and edit validation submitted by Clients and Providers to ensure any updates to coding, pricing, and any other data fields in system.
• Contributes towards the daily identification and retention of additional Client savings in high volume claim environment driving monthly, quarterly additional revenue gains for Zelis.
• Monitor turnaround time to ensure timely processing of claims in accordance with Client’s Service Level Agreement (SLA) to ensure compliance and prevent negative financial impact.
• Act as a resource to identify edit discrepancies based on coding guidelines and Zelis processes to make recommendations for the modifications to the Operations and Product teams.
• Communicate and collaborate with internal colleagues to obtain and provide the appropriate content for Client and Provider inquiries
• Consistently demonstrate knowledge and understanding of Zelis Editing Product by utilizing current edit logic and coding guidelines to apply to the Claims Editing review determination
• Utilize industry standard tools and coding guidelines (including but not limited to AMA, CMS, and Zelis Internal Manuals)

PROFESSIONAL EXPERIENCE:

• 3+ years of relevant experience or equivalent combination of education & work within healthcare payer or provider.
• Certified coder (CCS, CCS-P or CPC), or RN, LPN with coding certification is required.
• Knowledge of healthcare reimbursement policies, state and federal regulations and applicable industry standards.
• Knowledge of correct coding and industry standard claim adjudication guidelines and policies.
• Ability to translate coding and adjudication guidelines, policies, and references into edit policies and rules.
• Excellent verbal & written communication skills with project management experience
• Proficient in Microsoft Office suite (Word, Excel, Power Point etc.)

EDUCATION:

Current active CPC or CCS or equivalent credentials required

Associate degree preferred

WORK ENVIRONMENT:

• Travel requirements to (primarily) domestic destinations should not exceed 10%.
• A standard work week exists but with the understanding that additional time/effort outside of the usual parameters can/will occur based upon the overall needs of the integration, where deadlines exist and when necessary due to the needs of the integration team.