Key responsibilities: + Review provider disputes for DRG C oding and C linical V alidation (MS and APR) , Itemized Bill Review (IBR) and Clinical Chart Review (CCR) and submit explanation of dispute rationale back to providers based on dispute findings within the designated timeframe to ensure client turnaround times are met. + Accountable for daily management of claim dispute volume , adhering to client turnaround time, and department Standard Operating Procedures + Serve as subject matter expert for the Expert Claim Review Team on day-to-day activities including troubleshooting and review for data accuracy. + Serve as a subject matter expert for content and bill review s and provide support where needed for inquiries and research requests. + Create and present education to Expert Claim Review Teams and other departments dispute findings . + Research and analysis of content for bill review . + 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, CCR Review Guidelines and Templates, and Dispute Rationales + Perform regulatory research from multiple sources to keep abreast of compliance enhancements and additional bill review opportunities. + Support for client facing teams as needed relating to client inquiries related to provider disputes . + Utilize the most up-to-date approved Zelis medical coding sources for bill review maintenance . + Communicate and partner with CMO and members of Expert Claim Review Product and Operations teams regarding important issues and trends. + Ensure adherence to quality assurance guidelines . + Monitor, research, and summarize trends, coding practices, and regulatory changes . + Actively contribute new ideas and support ad hoc projects, including time-sensitive requests. + Ensure adherence to quality assurance guidelines . + Maintain awareness of and ensure adherence to ZELIS standards regarding privacy . Skills, Knowledge, and experience: + 5+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferred + Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers + Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs + Understanding of hospital coding and billing rules + Clinical skills to evaluate appropriate Medical Record Coding + Experience performing regulatory research from multiple sources , formulating an opinion, and presenting findings in an organized , concise manner . + Background and /o r understanding of the healthcare industry . + K nowledge 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 . + Consistently demonstrate ability to act and react swiftly to continuous challenges and changes . + Excellent analytical skills with data and analytics related solutions . + Excellent communication skills . + Strong organization and project/process management skills . + Strong initiative, self-directed and self-motivation . + Good negotiation, problem solving, planning and decision-making skills . + Ability to manage projects simultaneously and achieve goals . + Excellent follow through, attention to detail, and time management skills . education: + Current, active Inpatient Coding Certification required ( ie . CCS, CIC, RHIA , RHIT, CPC or equivalent credentialing ) . + Registered Nurse licensure preferred + Bachelor’s Degree Preferred in business, healthcare, or technology preferred. Zelis is modernizing the healthcare financial experience by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. This platform serves more than 750 payers, including the top 5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts – driving real, measurable results for clients. Commitment to Diversity, Equity, Inclusion, and Belonging At Zelis, we champion diversity, equity, inclusion, and belonging in all aspects of our operations. We embrace the power of diversity and create an environment where people can bring their authentic and best selves to work. We know that a sense of belonging is key not only to your success at Zelis, but also to your ability to bring your best each day. 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 encourage members of traditionally underrepresented communities to apply, even if you do not believe you 100% fit the qualifications of the position, including women, LGBTQIA people, people of color, and people with disabilities. 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. Zelis is modernizing the healthcare financial experience by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. This platform serves more than 750 payers, including the top 5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts – driving real, measurable results for clients.