Dispute Resolution II

Role Overview: You will be responsible for reviewing provider disputes related to DRG Coding and Clinical Validation, Itemized Bill Review, and Clinical Chart Review. Your main tasks will include analyzing disputes, providing explanations based on findings, managing claim dispute volume, and ensuring adherence to client turnaround times and department procedures. Additionally, you will serve as a subject matter expert for the Expert Claim Review Team, creating educational materials, conducting research, and maintaining bill review content. Key Responsibilities: - Review provider disputes for DRG Coding and Clinical Validation, Itemized Bill Review, and Clinical Chart Review - Submit explanation of dispute rationale back to providers based on dispute findings within designated timeframe - Manage daily claim dispute volume and adhere to client turnaround time and department SOPs - Serve as a subject matter expert for the Expert Claim Review Team on day-to-day activities - Provide support for content and bill reviews, inquiries, and research requests - Create and present education to Expert Claim Review Teams and other departments on dispute findings - Research and analyze content for bill review - Use strong coding and industry knowledge to create and maintain bill review content - Perform regulatory research to stay updated on compliance enhancements and bill review opportunities - Support client facing teams with inquiries related to provider disputes - Utilize approved Zelis medical coding sources for bill review maintenance - Communicate and partner with relevant teams regarding important issues and trends - Ensure adherence to quality assurance guidelines - Monitor, research, and summarize trends, coding practices, and regulatory changes - Contribute new ideas and support ad hoc projects - Maintain awareness of and ensure adherence to Zelis standards regarding privacy Qualification Required: - 5+ years reviewing and/or auditing ICD-10 CM, MS-DRG, and APR-DRG claims preferred - Solid understanding of audit techniques, revenue opportunities identification, and financial negotiation - Experience and working knowledge of Health Insurance, Medicare guidelines, and healthcare programs - Understanding of hospital coding and billing rules - Clinical skills for evaluating appropriate Medical Record Coding - Experience in performing regulatory research, formulating opinions, and presenting findings - Background or understanding of the healthcare industry - Knowledge of National Medicare and Medicaid regulations - Strong analytical, communication, organization, and project management skills - Coding certification required (eg. CCS, CIC, RHIA, RHIT, CPC or equivalent) - Registered Nurse licensure preferred - Bachelor's Degree preferred in business, healthcare, or technology Please note that Zelis promotes diversity, equity, inclusion, and belonging in all aspects of its operations and encourages members of traditionally underrepresented communities to apply. If you require accessibility support during the application process, please reach out to TalentAcquisition@zelis.com.,