Expert Claims Product Analyst (Concept Ideation)

At Zelis, we Get Stuff Done. So, let's get to it!

A Little About Us

Zelis is modernizing the healthcare financial experience 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.

At Zelis, AI is woven into the fabric of how we work. Every associate is expected - and empowered - to partner with AI to challenge the status quo, accelerate innovation, and amplify their impact. This is a place for builders with a growth mindset who act with agility, embrace change, and use modern technology to shape smarter solutions, exceptional experiences, and the future of our industry for our clients, customers, and our culture.

A Little About You

You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are.

Position Overview

What You'll Do:

• Serve as subject matter expert for the Ideation Team on day-to-day activities including troubleshooting and review for data accuracy
• Review provider disputes for DRG and IBR and submit explanation of dispute rationale back to providers based on dispute findings within the designated timeframe to ensure client turnaround times are met
• 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 Operations team and CMO along with potentially other departments on new and updated concepts, review guidelines, and dispute findings
• Research and analysis of content for Itemized Bill Review and DRG Validation
• 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, and Dispute Rationales
• Perform regulatory research from multiple sources to keep abreast of compliance enhancements and additional bill review opportunities.
• Analysis of data to assess impact for content related issues or defects. Contribute to product alerts and partner with Product Management on notifications
• Utilize the most up-to-date approved Zelis medical coding sources for bill review maintenance and development
• Partner with other areas to assess and communicate impact to the business for additions, changes, or updates as it relates to content and bill review updates
• Communicate and partner with CMO and members of Operations or Product teams regarding important changes, issues, and trends
• Ensure adherence to quality assurance guidelines
• Monitor, research, and summarize trends, coding practices, and regulatory changes
• Provide recommendations for enhancements or trends relating to content expansion, automation, and efficiencies
• Actively contribute new ideas and support ad hoc projects, including time-sensitive requests
• Collaborate with Sales, Marketing and Product on updating bill review artifacts
• Maintain awareness of and ensure adherence to Zelis standards regarding privacy

What You'll Bring to Zelis:

• Current, active CIC or CCS or equivalent credentialing is required
• RN or LPN with coding certification, or certified coder, or registered health information technician (RHIA/RHIT) with at least 6-8 years of experience
• Experience with MS-DRG/APR-DRG coding and compliance required
• Experience performing regulatory research from multiple sources, formulating an opinion, and presenting findings in an organized, concise manner
• 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
• Ability to leverage reporting tools to research claim data, trending and analysis for concept ideation processes
• Understanding of JIRA/Confluence recommended
• Strong organization and project/process management skills

INDEPENDENCE/ ACCOUNTABILITY:

• Ability to manage and prioritize multiple tasks, be a self-starter and meet deadlines with professional manner and respect for confidentiality
• A self-motivator who follows detailed instructions, tracks progress against goals and regularly reviews goals / objectives with supervisor

COMMUNICATION SKILLS:

• Able to communicate accurately, honestly, and effectively, both in oral and written form, practices active listening
• Clearly conveys information and ideas through a variety of media to individuals and groups in a manner that engages the audience and helps them understand the information

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

Zelis is headquartered in the U.S., with multiple locations across the country and in Hyderabad, India. Check out our locations to learn more about our offices. All employee work locations are based on the needs of the position and are determined by the Leadership team. In-office work and activities vary based on work and team objectives in accordance with Company policies.

While location expectations vary by role, candidates within approximately 50 miles of a U.S. office are generally preferred to support collaboration when needed. Our hybrid approach is flexible, and in-office presence is guided by team and business needs rather than a fixed weekly schedule.

Base Salary Range

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.