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Clinical Coding Policy Analyst

Company: Zelis Healthcare, LLC
Location: Saint Petersburg
Posted on: April 3, 2024

Job Description:


  • Provide in-depth clinical coding analysis of professional and facility claims routed to the Clinical Coding Policy queue based on new or updated edit logic.
  • Works well with a team.
  • Provide in-depth research on Coding Scenarios.
  • Communication and a team-work approach.
  • Identify and provide root-cause analysis of edit performance issues.
  • Advise leadership if edits are working as intended and support decision with validation data.
  • Assist in creating and maintaining job aides aimed at promoting consistency in clinical validations and claims workflow process improvements.
  • Assist in the submission of IT requests associated with validations and the enhancement of reports/tools needed to maximize results.
  • Maintain current industry knowledge of claim edit references including, but not limited to: AMA, CMS, NCCI.
  • Assists in the documentation of updated process, guidelines for review, enhancements, and automation.
  • Work closely with leadership in departmental functions and special projects.
  • Work closely with the resolution analysts.JOB REQUIREMENTS
    • 2+ years of relevant experience or equivalent combination of education & work within healthcare payers/claims payment processing
    • Certified Coder (CCS, CCS-P or CPC)
    • RN, LPN or LVN preferred
    • Ability to interpret claim edit rules and references
    • Solid understanding of claims workflow and the ability to interpret professional and facility claim forms
    • Knowledge of payer reimbursement policies, state and federal regulations and applicable industry standards
    • Ability to apply industry coding guidelines to claim processes
    • Strong understanding of Clinical Policy interpretation required
    • Ability to perform audits of claims processes and apply root-cause
    • Ability to manipulate data in Excel
    • Experience managing business relationships
    • Excellent verbal & written communication skills
    • 1+ years of experience in review of Medical Records and application of NCCI editingEducation:Associates Degree or Bachelor's Degree preferredRN or LPNCurrent, active CPC or equivalent credentialing requiredAs a leading payments company in healthcare, we guide, price, explain, and pay for care on behalf of insurers and their members. We're Zelis in our pursuit to align the interests of payers, providers, and consumers to deliver a better financial experience and more affordable, transparent care for all. We partner with more than 700 payers, including the top-5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, over 4 million providers, and 100 million members, enabling the healthcare industry to pay for care, with care. Zelis brings adaptive technology, a deeply ingrained service culture, and a comprehensive navigation through adjudication and payment platform to manage the complete payment process.Commitment to Diversity, Equity,Inclusion, and BelongingAt 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 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 SupportWe 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 SCAM ALERT: There is an active nationwide employment scam which is now using Zelis to garner personal information or financial scams. This site is secure, and any applications made here are with our legitimate partner. If you're contacted by a Zelis Recruiter, please ensure whomever is contacting you truly represents Zelis Healthcare. We will never asked for the exchange of any money or credit card details during the recruitment process. Please be aware of any suspicious email activity from people who could be pretending to be recruiters or senior professionals at Zelis.

Keywords: Zelis Healthcare, LLC, St. Petersburg , Clinical Coding Policy Analyst, Professions , Saint Petersburg, Florida

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