Clinical Dispute Analyst

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.

Key responsibilities :

Review provider disputes for DRG Coding and Clinical Validation (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 reviews 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.

Skills, Knowledge, and experience :

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 / or understanding of the healthcare industry.

Knowledge of National Medicare and Medicaid regulations.

Knowledge of payer reimbursement policies.

Excellent analytical skills with data and analytics related solutions.

Strong organization and project / process management skills.

Good negotiation, problem solving, planning and decision-making skills.

Excellent follow through, attention to detail, and time management skills.

Travel requirements to (primarily) domestic destinations should not exceed 10%.

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.