Clinical Dispute Analyst

Zelis•Plano, TX

8d•$71,000 - $95,000•Hybrid

About The Position

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. 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 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 TPA’s 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.

Requirements

5+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferred
Current, active Inpatient Coding Certification required ( ie . CCS, CIC, RHIA , RHIT, CPC or equivalent credentialing ) .
Registered Nurse licensure preferred
Bachelor’s Degree Preferred in business, healthcare, or technology 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 /o r understanding of the healthcare industry .
K nowledge 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 .

Nice To Haves

5+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferred
Registered Nurse licensure preferred
Bachelor’s Degree Preferred in business, healthcare, or technology preferred.

Responsibilities

Review provider disputes for DRG C oding and C linical V alidation (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 review s 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 important issues and trends.
Ensure adherence to quality assurance guidelines .
Monitor, research, and summarize trends, coding practices, and regulatory changes .
Actively contribute new 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 .

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.

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