Dispute Resolution II

2 Months ago • 3 Years +

Job Summary

Job Description

The Certified Claim Editing Resolution Analyst II will review medical records for complex provider claims, ensuring appropriately coded services based on the Zelis Claim Edits Product. They will resolve complex inquiries, validate claims, and respond to disputes. This role involves identifying and retaining client savings, monitoring turnaround times, and recommending improvements to the Operations and Product teams. The analyst will communicate with internal colleagues and utilize industry standard tools and coding guidelines to make informed decisions. The role requires a certified coder or equivalent qualification and relevant experience in healthcare reimbursement.
Must have:
  • Review medical records for complex claims
  • Resolve complex inquiries and disputes
  • Identify and retain client savings
  • Monitor turnaround times for claims processing
  • Communicate with internal colleagues effectively
  • Use industry-standard tools and coding guidelines
  • Certified coder (CCS, CCS-P, or CPC) or equivalent

Job Details

About Us 

Zelis is modernizing the healthcare financial experience in the United States (U.S.) 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 health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers in the U.S. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts—driving real, measurable results for clients.  

Why We Do What We Do 

In the U.S., consumers, payers, and providers face significant challenges throughout the healthcare financial journey. Zelis helps streamline the process by offering solutions that improve transparency, efficiency, and communication among all parties involved. By addressing the obstacles that patients face in accessing care, navigating the intricacies of insurance claims, and the logistical challenges healthcare providers encounter with processing payments, Zelis aims to create a more seamless and effective healthcare financial system.

Zelis India plays a crucial role in this mission by supporting various initiatives that enhance the healthcare financial experience. The local team contributes to the development and implementation of innovative solutions, ensuring that technology and processes are optimized for efficiency and effectiveness. Beyond operational expertise, Zelis India cultivates a collaborative work culture, leadership development, and global exposure, creating a dynamic environment for professional growth. With hybrid work flexibility, comprehensive healthcare benefits, financial wellness programs, and cultural celebrations, we foster a holistic workplace experience. Additionally, the team plays a vital role in maintaining high standards of service delivery and contributes to Zelis’ award-winning culture. 

Position Overview

The Certified Claim Editing Resolution Analyst II will be responsible for reviewing and researching medical records for complex, multi-specialty provider claims to identify and determine appropriately coded billed services when compared to the Zelis Claim Edits Product. The Certified Claim Editing Resolution Analyst II is responsible for processing, validating, routing, and responding to mid-level complex incoming Client and Provider corrected claims, disputes and inquires.

ESSENTIAL FUNCTIONS:

  • Research medical records for complex and multi-specialty provider claims with the objective of determining appropriately coded billed services when compared to the Zelis Claim Edits Product and to maintain the editing product integrity
  • Review and resolve complex inquiries up to identified targeted edit savings on corrected claims, disputes and edit validation as a team resource to retain savings.
  • Identify any update information on the corrected claims, disputes and edit validation submitted by Clients and Providers to ensure any updates to coding, pricing, and any other data fields in system.
  • Contributes towards the daily identification and retention of additional Client savings in high volume claim environment driving monthly, quarterly additional revenue gains for Zelis.
  • Monitor turnaround time to ensure timely processing of claims in accordance with Client’s Service Level Agreement (SLA) to ensure compliance and prevent negative financial impact.
  • Act as a resource to identify edit discrepancies based on coding guidelines and Zelis processes to make recommendations for the modifications to the Operations and Product teams.
  • Communicate and collaborate with internal colleagues to obtain and provide the appropriate content for Client and Provider inquiries 
  • Consistently demonstrate knowledge and understanding of Zelis Editing Product by utilizing current edit logic and coding guidelines to apply to the Claims Editing review determination 
  • Utilize industry standard tools and coding guidelines (including but not limited to AMA, CMS, and Zelis Internal Manuals)

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:

Current 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.

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About The Company

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.

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