Position Overview:

At Zelis, the Itemized Bill Review Facility Reviewer is responsible for analyzing facility inpatient and outpatient claims for Health Plans and ensuring adherence to proper billing guidelines. They will work closely with Expert Claims Review and Concept Development staff to efficiently identify and adhere to policies and procedures for claims processing. This position will also be responsible for developing new concepts, assisting with the quality assurance program, and being a resource for the entire organization regarding IBR claims. This is a production-based role with production metrics goals.

Key responsibilities:

• Conduct detailed review of hospital itemized bills for identification of billing and coding opportunities for all payor’s claims including restricted list

• Review client payment policy documents: interpret and document the configurations to be applied to Zelis coding and clinical reviews

• Translate client reimbursement policies into Zelis coding and clinical concepts

• Provide direction to internal team based on understanding of client payment policies

• Understand payor policies and their application to claims processing

• Prepare and upload documentation clearly identifying findings

• Accurately calculate/verify the value of review and documentation for claim processing

• Monitor multiple reports to track client specific requirements, turnaround time and overall claims progression

• Complete claims processing after the Clinical Bill Review and Audit analysis is completed.

• Assist in appeals process as necessary

• Collaborate between multiple areas within the department

• Evaluate current Quality Assurance Process and implement recommended changes for efficiency & effectiveness

• Monitor, research, and summarize changes as client reimbursement policy changes

• Lend expertise to implementation team as necessary

• Act as a coding subject matter expert for department and clients

• Remain current in all national coding guidelines including Official Coding Guidelines and AHA Coding Clinic and share with review team

• Maintain awareness of and ensure adherence to Zelis standards regarding privacy

JOB REQUIREMENTS:

Technical Skills / Knowledge:

• CPC credential preferred

• Working knowledge of health/medical insurance and handling of claims

• General knowledge of provider claims/billing, with medical coding and billing experience

• Knowledge of ICD-10 and CPT coding

• Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers

• Ability to manage and prioritize multiple tasks with strong attention to detail

• Diligent research and organizational skills

• Excellent verbal and written communication skills

• Proficient in Microsoft Office, more importantly Outlook, Excel, and Word

Independence/ Accountability:

• Savings acceptance threshold not to exceed TBC $500,000.00

• Maintain individual productivity standard of 10 claims accepted per day

• Consistently meet or exceed personal quality standard of 85%

• Requires minimal daily supervision.

• Regularly reviews goals and objectives with supervisor.

• Ability to follow detailed instructions on new assignments.

• Accountable to day-to-day tasks.

• Ability to manage and prioritize multiple tasks.

• Ability to work under pressure and meet deadlines.

Problem Solving:

• Makes logical suggestions as to likely causes of problems and independently recommends solutions.

• Excellent organizational skills are required to prioritize responsibilities, thus completing work in a timely fashion.

• Outstanding ability to multiplex tasks as required.

• Excellent project management skills.

• Attention to detail and concern for impact is essential.

Communication Skills:

• Must work well with others.

• Effectively communicate with others by giving and receiving feedback.

• Communicates ideas and information clearly.

• Must have excellent communication and presentation skills to effectively interface with the entire staff, and external representatives from the business, financial, legal, and scientific communities

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 of our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies.

Zelis is modernizing the healthcare financial experience by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. This platform serves more than 750 payers, including the top 5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts – driving real, measurable results for clients.

Commitment to Diversity, Equity, Inclusion, and Belonging
At Zelis, we champion diversity, equity, inclusion, and belonging in all aspects of our operations. We embrace the power of diversity and create an environment where people can bring their authentic and best selves to work. We know that a sense of belonging is key not only to your success at Zelis, but also to your ability to bring your best each day.

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 encourage members of traditionally underrepresented communities to apply, even if you do not believe you 100% fit the qualifications of the position, including women, LGBTQIA people, people of color, and people with disabilities.

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 TalentAcquisition@zelis.com.

SCAM ALERT: There is an active nationwide employment scam which is now using Zelis to garner personal information or financial scams. This site is secure, and any applications made here are with our legitimate partner. If you’re contacted by a Zelis Recruiter, please ensure whomever is contacting you truly represents Zelis Healthcare. We will never asked for the exchange of any money or credit card details during the recruitment process. Please be aware of any suspicious email activity from people who could be pretending to be recruiters or senior professionals at Zelis.