Job Description

At Zelis, the Itemized Bill Review Facility Reviewer is responsible for analyzing facility inpatient and outpatient claims for Health Plans, ensuring adherence to proper billing guidelines. They will collaborate closely with Hospital Bill Review and Concept Development staff to efficiently identify and adhere to policies and procedures for claims processing. This position also involves developing new concepts, assisting with the quality assurance program, and serving as a resource for the organization regarding IBR claims. This is a production-based role with specific production metrics goals. Key Responsibilities : Conduct detailed reviews of hospital itemized bills to identify billing and coding opportunities across all payor claims, including restricted lists. Review client payment policy documents, interpret, and document configurations for Zelis coding and clinical reviews. Translate client reimbursement policies into Zelis coding and clinical concepts. Provide guidance to internal teams based on understanding of client payment policies. Understand payor policies and their application to claims processing. Prepare and upload documentation clearly outlining findings. Accurately calculate and verify review values and documentation for claim processing. Monitor reports to track client-specific requirements, turnaround times, and overall claims progression. Complete claims processing following Clinical Bill Review and Audit analysis. Assist in appeals processes as needed. Collaborate across multiple areas within the department. Evaluate and improve the Quality Assurance process for efficiency and effectiveness. Monitor, research, and summarize changes in client reimbursement policies. Maintain a productivity standard of 12 claims accepted per day with a savings acceptance threshold up to $1,000,000.00. Meet or exceed a personal quality standard of 85%. Provide expertise to implementation teams as necessary. Act as a coding subject matter expert for the department and clients. Stay current with national coding guidelines, including Official Coding Guidelines and AHA Coding Clinic, and share updates with the review team. Ensure adherence to Zelis standards regarding privacy. Qualifications : CPC credential preferred. Working knowledge of health/medical insurance and claims processing. General knowledge of provider claims/billing, with medical coding and billing experience. Knowledge of ICD-10 and CPT coding. Understanding of audit techniques, revenue opportunities, and financial negotiations with providers. Ability to manage multiple tasks with strong attention to detail. Research and organizational skills. Excellent verbal and written communication skills. Ability to work under pressure, meet deadlines, and prioritize tasks. Proficiency in Microsoft Office, especially Outlook, Excel, and Word. Strong organizational and project management skills. Effective communication and presentation skills for interfacing with staff and external stakeholders. 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 support a hybrid and remote-friendly culture, with work location determined by the position's needs and leadership decisions. In-office activities vary based on work and team objectives in line with company policies. #J-18808-Ljbffr Zelis

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