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Coding Validation Analyst at Zelis Healthcare

Coding Validation Analyst

General information

  • Position level: Associate
  • Working time: Full-time
  • Type of contract: Permanent
  • Location: Field/Remote Office

Description & Requirements

KEY COMPETENCIES:

The Coding Validation Analyst manages the Coding Validation queues and is responsible for documenting results of claims performance for new/updated edits through claims review based on new or updated edit logic. This will include analysis/reporting of edit performance and root-cause research of edits that may not perform as intended. The Claims Validation Analyst supports the Claims Editing department with ad-hoc requests from other departments that involve claim validations and all tasks associated with the support of claim workflows relating to Claims Editing.

ESSENTIAL FUNCTIONS:

  • Provide in-depth analysis of professional and facility claims routed to the manual claims validation queue based on new or updated edit logic.
  • Document daily claims performance for each edit and advise management of any significant performance issues immediately.
  • Work closely with Coding Specialist(s), Appeals, Implementation, PMO & Acct Mgmt at the direction of management to report on validation of claims for edits created in new edit platforms.
  • Identify and provide root-cause analysis of edit performance issues.
  • Advise management if edits are working as intended and support decision with validation data.
  • Manage relationships with Doc Retrieval, IT, and Ops Mgmt to ensure tools needed for validation (i.e., claim images) are readily available to ensure completeness of review and research.
  • Assist in creating and maintaining job aides aimed at promoting consistency in 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.
  • Work closely with Manager of Coding Validation and Associate Director of Edit Operations in departmental functions and special projects

JOB REQUIREMENTS:

  • 2-5+ years of relevant experience or equivalent combination of education & work within healthcare payers/claims payment processing
  • Certified Coder (CCS, CCS-P or CPC) Required
  • 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
  • Ability to apply industry coding guidelines to claim processes
  • 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

Zelis is a healthcare and financial technology growth company and market-leading provider of claims cost management and payments optimization solutions to price, pay and explain healthcare claims. Zelis delivers integrated network analytics, network solutions, payment integrity, electronic payments and claims communications for payers, healthcare providers and consumers in the medical, dental and workers’ compensation markets nationwide. Zelis is backed by Parthenon Capital Partners and Bain Capital.

“We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.”

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