About Us
Zelis is modernizing the healthcare financial experience in the United States (U.S.) across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. 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 Clinical Policy Review Analyst is a subject matter expert that clinically reviews claims within the Clinical Policy Review queues and is responsible for maintaining up-to-date clinical guidelines for review of these claims. The Clinical Coding Policy Analyst is also responsible for reviewing the disputes from providers for the edits that were accepted in this queue. This will include analysis and research of specific coding scenarios as well as assisting in edit ideation and maintaining review guidelines.ESSENTIAL FUNCTIONS
- Provide in-depth clinical coding analysis of professional and facility claims routed to the Clinical Policy Review queue based on new or updated edit logic.
- Works well with a team.
- Provide in-depth research on Coding Scenarios.
- Communication and a team-work approach.
- Identify and provide root-cause analysis of edit performance issues.
- Advise leadership if edits are working as intended and support decision with validation data.
- Assist in creating and maintaining job aides aimed at promoting consistency in clinical validations and claims workflow process improvements.
- Assist in the submission of IT requests associated with validations and the enhancement of reports/tools needed to maximize results.
- Maintain current industry knowledge of claim edit references including, but not limited to: AMA, CMS, NCCI.
- Assists in the documentation of updated process, guidelines for review, enhancements, and automation.
- Work closely with leadership in departmental functions and special projects.
- Work closely with the resolution analysts.
JOB REQUIREMENTS
- 2+ years of relevant experience or equivalent combination of education & work within healthcare payers/claims payment processing
- Certified Coder (CCS, CCS-P or CPC)
- RN, LPN or LVN preferred
- Ability to interpret claim edit rules and references
- Solid understanding of claims workflow and the ability to interpret professional and facility claim forms
- Knowledge of payer reimbursement policies, state and federal regulations and applicable industry standards
- Ability to apply industry coding guidelines to claim processes
- Strong understanding of Clinical Policy interpretation required
- Ability to perform audits of claims processes and apply root-cause
- Ability to manipulate data in Excel
- Experience managing business relationships
- Excellent verbal & written communication skills
- 1+ years of experience in review of Medical Records and application of NCCI editing
Education:
RN or LPN, Bachelor’s Degree preferred
Current, active CPC or equivalent credentialing required
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 Clinical Policy Review team.
- Ability to sit for extended periods of time.
