IBR Facility Reviewer

Responsibilities

• Conduct detailed review of hospital itemized bills for identification of billing and coding opportunities for all payor's claims including restricted list
• Review client payment policy documents; interpret and document the configurations to be applied to Zelis coding and clinical reviews
• Translate client reimbursement policies into Zelis coding and clinical concepts
• Provide direction to internal team based on understanding of client payment policies
• Understand payor policies and their application to claims processing
• Prepare and upload documentation clearly identifying findings
• Accurately calculate/verify the value of review and documentation for claim processing
• Monitor multiple reports to track client specific requirements, turnaround time and overall claims progression
• Complete claims processing after the Clinical Bill Review and Audit analysis is completed
• Assist in appeals process as necessary
• Collaborate between multiple areas within the department
• Evaluate current Quality Assurance Process and implement recommended changes for efficiency & effectiveness
• Monitor, research, and summarize changes as client reimbursement policy changes
• Lend expertise to implementation team as necessary
• Act as a coding subject matter expert for department and clients
• Remain current in all national coding guidelines including Official Coding Guidelines and AHA Coding Clinic and share with review team
• Maintain awareness of and ensure adherence to Zelis standards regarding privacy
• What You'll Bring to Zelis:
• 1-2 years experience in a related role
• CPC credential preferred
• Working knowledge of health/medical insurance and handling of claims
• General knowledge of provider claims/billing, with medical coding and billing experience
• Knowledge of ICD-10 and CPT coding
• Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers
• Ability to manage and prioritize multiple tasks
• Excellent verbal and written communication skills
• 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
• 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.
• Equal Employment Opportunity
• Zelis is proud to be an equal opportunity employer. All qu

Benefits

Additional Information

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 At Zelis, the Itemized Bill Review Facility Reviewer is responsible for analyzing facility inpatient and outpatient claims for Health Plans and ensuring adherence to proper billing guidelines. They will work closely with Hospital Bill Review and Concept Development staff to efficiently identify and adhere to policies and procedures for claims processing. This position will also be responsible for developing new concepts, assisting with the quality assurance program, and being a resource for the entire organization regarding IBR claims. This is a production-based role with production metrics goals.

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