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Position Overview:

The Certified Edit Dispute Resolution Analyst will be responsible for researching and auditing medical records for complex, diverse, multi-specialty provider claims to identify and determine appropriately coded billed services when compared to the Zelis Claim Edits Product. The Certified Edit Dispute Resolution Analyst demonstrates an understanding of Zelis edits as an individual contributor for processing, escalating, routing, and responding to complex incoming Client and Provider disputes.

Key Responsibilities:

• Review and approve complex, high dollar inquiries up to identified targeted edit savings on Disputes as an individual contributor and as a team resource to guide others on process
• Consistently demonstrate strong expertise and understanding of Zelis Editing Product. You will utilize current edit logic and coding guidelines to apply to the disputes review determination to capture highest revenue savings, as appropriate
• Research and audit medical records for complex and multi-specialty provider claims with an objective to determine appropriately coded billed services compared to the Zelis Claim Edits Product
• Communicate and collaborate with internal and external colleagues to obtain and provide the appropriate content for Client and Provider inquiries
• Monitor turnaround time to ensure timely processing of claims in accordance with Client's Service Level Agreement (SLA) to ensure complianceand prevent negative financial impact
• Participate in Provider-facing calls with Zelis Customer Call Center on behalf of the client to explain the rationale behind edit logic to support edit determination
• Act as a resource to identify edit discrepancies based on coding guidelines, trending analysis and Zelis processes to make recommendations for the modifications to the Operations and Product teams
• Utilize industry standard tools and coding guidelines (including but not limited to AMA, CMS, and Zelis Internal Manuals)
• Communicate with Supervisor and team members in a proactive manner to ensure the timely delivery of objectives and tasks

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:

• 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.

As a leading payments company in healthcare, we guide, price, explain, and pay for care on behalf of insurers and their members. We're Zelis in our pursuit to align the interests of payers, providers, and consumers to deliver a better financial experience and more affordable, transparent care for all. We partner with more than 700 payers, including the top-5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, over 4 million providers, and 100 million members, enabling the healthcare industry to pay for care, with care. Zelis brings adaptive technology, a deeply ingrained service culture, and a comprehensive navigation through adjudication and payment platform to manage the complete payment process.

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 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

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