Clinical Dispute Reviewer

Position Overview

The Clinical Dispute Reviewer is responsible for conducting comprehensive clinical reviews of medical records, claims, and other healthcare documentation to ensure compliance with clinical guidelines, regulatory requirements, and organizational policies. This individual will play a critical role in supporting the quality and integrity of our clinical review processes, providing expert guidance, and contributing to the continuous improvement of our healthcare services. The ideal candidate will have extensive clinical experience, strong analytical skills, and a deep understanding of healthcare regulations and standards.

What you’ll do:

• 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 reviews
• 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 medical coding sources for bill review maintenance.
• Communicate and partner with CMO and members of Expert Claim Review Product and Operations teams regarding critical issues and trends
• Ensure adherence to quality assurance guidelines
• Monitor, research, and summarize trends, coding practices, and regulatory changes
• Actively contribute innovative ideas and support ad hoc projects, including time-sensitive requests.
• Ensure adherence to quality assurance guidelines.
• Maintain awareness of and ensure adherence to standards regarding privacy.

What you’ll bring to Zelis:

• Current, active Inpatient Coding Certification required (i.e., CCS, CIC, RHIA, RHIT, CPC or equivalent credentialing).
• Registered Nurse licensure preferred
• Bachelor’s degree in business, healthcare, or technology preferred.
• 5+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims 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
• 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.

Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future.

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 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.

Base Salary Range

$95,000.00 - $127,000.00

At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role.

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.

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 welcome applicants from all backgrounds and encourage you to apply even if you don’t meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all.

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.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.