CPC/CCS Senior Edit Resolution Analyst

Zelis•Atlanta, GA

1d•Hybrid

About The Position

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. The CPC/CCS Senior Edit Resolution Analyst will handle highly complex grievance and appeal cases and serves as a subject matter expert within the Resolution team. The position operates with significant autonomy, provides guidance to junior staff, and contributes to the development of SOPs and process optimization initiatives.

Requirements

CPC or CCS or equivalent credentials required
3+ yrs related coding experience
Requires proficiency using AI tools skillfully with an understanding of how to develop/create intelligent prompts and/or agents
Advanced knowledge of grievance and appeals handling in healthcare
Proven ability to coach and mentor junior staff
Experience in SOP development and process optimization
Strong problem-solving and communication skills
Ability to manage elevated and complex cases with minimal supervision

Nice To Haves

Associates degree preferred

Responsibilities

Manage escalated and high-risk grievance and appeal cases requiring advanced regulatory knowledge and critical thinking to ensure timely and compliant resolution.
Serve as a resource for complex inquiries from peers and leadership; interpret regulatory changes and advise on operational impacts.
Lead or contribute to the creation and refinement of SOPs, job aids, and training materials to ensure alignment with evolving regulations and organizational goals.
Provide structured guidance and coaching to junior associates, fostering skill development and adherence to quality standards.
Partner with other teams to address systemic issues, mitigate risks, and implement corrective actions.
Identify opportunities for automation, workflow redesign, and efficiency improvements; present recommendations to leadership.
Conduct peer reviews and audits of case handling to ensure accuracy, compliance, and consistency across the team.
Participate in departmental projects and initiatives aimed at improving grievance and appeals operations and member experience.
Serve as a subject matter expert on regulatory compliance and dispute resolution.
Analyze data to identify trends and recommend systemic improvements.
Drive innovation in resolution practices to enhance member experience and compliance.