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 The Senior Concept Ideation Analyst, Bill Review role is responsible for development and delivery of initiatives focused on bill review content management. The Ideation Team researches and produces new bill review content as well as enhances existing bill review content using sources such as ICD-10, AHA, AMA, CPT, AAPC, CMS and/or clinical research sources. This role partners closely with the team in producing clinical content for bill reviews of facility claims including support for communication and documentation. They will work closely with Operations and Product teams in the development and maintenance of the content as it relates to scalability, functionality, and initiatives imperative to growth.

The primary focus will be concept development for DRG Coding and Clinical Validation (MS and APR) and also includes Itemized Bill Review (IBR).

Key Responsibilities

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

Key Qualifications

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:

Regularly reviews goals and objectives with supervisor

Must have professional manner and respect the confidentiality of administrative matters and files

Ability to manage and prioritize multiple tasks

Ability to be a self-starter and meet deadlines

Ability to follow detailed instructions on assignments, where necessary

Ability to be a self-motivator and track against personal goals

COMMUNICATION SKILLS:

Must work well with others

Communicates 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 $105,000.00 - $133,000.00

At Zelis we are committed to providing fair and equitable compensation packages. The base salary ra