Zelis is a healthcare information technology company and market-leading provider of end-to-end healthcare claims cost management and payment solutions. Inc.5000 award winner: One of the fastest growing privately held companies in the US! Ranked #1 by NJ Biz as the Fastest Growing Company in NJ! COMPANY BACKGROUND/CULTURE
Zelis Healthcare is an information technology company which utilizes an end-to-end technology platform to fulfill the claims cost management and payments needs of healthcare payors including large and medium-sized health plans, TPAs, Taft-Hartley Plans, providers and individuals. The company provides a comprehensive portfolio of network management, claims integrity, payment remittance solutions and analytical services for medical, dental and workers’ compensation claims to over 500 payor clients. Additionally, the company delivers electronic payments and explanation of payments to over 200,000 healthcare providers and serves individuals with provider lookup and medical referral services.
The Senior Coding Research Analyst is responsible for conducting research relevant to claim edits for ZELIS clients, Medicare/Medicaid compliance and other coding related trends that may impact ZELIS business. This analyst will work with all operational areas of Zelis to develop and incorporate new edits and related business processes into the ZELIS claim review process.
- Form a solid understanding of the available edits via current edit vendor to determine appropriate edits for ZELIS clientele
- Research and recommend new edits to be incorporated into Claims Editing including but not limited to conducting research, documenting rules & logic and overall management of project process
- Research current edits that exist today and work with Business Analyst to document logic and rationale for purpose of re-engineering edit platform
- Research relating to the Center for Medicare & Medicaid Services, AMA and other industry sources and keeping abreast of compliance and opportunities
- Work closely with ZELIS teams in the creation of business models applicable to Claims Editing for Commercial, Medicare & Medicaid payors
- Assist the Medical Director in all aspects of research relating to coding, clinical or other related research
- Work with Healthcare Economics team relating to analysis required to edit creation, maintenance and/or updating
- Create and maintain documentation relating to research
- Coordinate all documentation of existing edits and new edits for the purpose of ensuring Zelis coding specialists can use documentation for edit support
- Maintain awareness of and ensure adherence to Zelis standards regarding privacy.
- Extensive knowledge of inpatient/outpatient hospital billing including UB-04s, revenue codes, itemization of charges, CPT codes, HCPCS codes, ICD-9/10 diagnosis and procedure codes, DRGs, APCs.
- Knowledge of payer reimbursement policies, state and federal regulations, medical necessity criteria and applicable industry standards.
- Knowledge of commonly used medical data resources such as MDR, medical fees in the US, etc.
- Knowledge of medical terminology, anatomy, and physiology.
- Ability to read and abstract medical records.
- Ability to develop educational materials and job aids pertaining to coding and claims.
- Minimum 5+ years’ experience in direct patient care, medical procedure billing, medical insurance auditing, line item review, audits, coding, and/or reimbursement.
- Required licensures, professional certifications, and/or Board certifications as applicable.
- Auditing and health information management experience in a healthcare setting preferred.
- Diligent research and organizational skills.
- Communicates ideas and information clearly.
- Knowledge and proficiency of Microsoft Word & Excel a must. Ability to manage and prioritize multiple tasks. Ability to work under pressure and meet deadlines.
- Makes logical suggestions for root cause of problems and independently suggests solutions.
- Attention to detail and concern for impact is essential and a top priority.
- Current certified coder (CCS, CCS-P or CPC), or Registered Health Information Technician (RHIA/RHIT)
- Bachelor’s Degree preferred plus at least 5 years of coding experience
- Current nursing certification a plus
COMPENSATION: An attractive compensation package as well as comprehensive benefits plans are available to attract outstanding candidates. Thank you for your interest in the Zelis team!
Location/Region: Bedminster, NJ (US)