Clinical Reviewer I

About the role

Zelis is modernizing the healthcare financial experience in the United States (U.S.) 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. Why We Do What We Do In the U.S., consumers, payers, and providers face significant challenges throughout the healthcare financial journey. Zelis helps streamline the process by offering solutions that improve transparency, efficiency, and communication among all parties involved. By addressing the obstacles that patients face in accessing care, navigating the intricacies of insurance claims, and the logistical challenges healthcare providers encounter with processing payments, Zelis aims to create a more seamless and effective healthcare financial system. Zelis India plays a crucial role in this mission by supporting various initiatives that enhance the healthcare financial experience. The local team contributes to the development and implementation of innovative solutions, ensuring that technology and processes are optimized for efficiency and effectiveness. Beyond operational expertise, Zelis India cultivates a collaborative work culture, leadership development, and global exposure, creating a dynamic environment for professional growth. With hybrid work flexibility, comprehensive healthcare benefits, financial wellness programs, and cultural celebrations, we foster a holistic workplace experience. Additionally, the team plays a vital role in maintaining high standards of service delivery and contributes to Zelis' award-winning culture. Position Overview The Itemized Bill Review Senior Analyst will be responsible for analyzing hospital claims for adherence to proper billing guidelines and will work closely with Expert Claims Review staff to efficiently adhere to policies and procedures for claims processing. This position will also be responsible for training and developing new team associates, report management, and acceptance of claims above the team members' threshold once analysis is complete. Assisting the manager and the team in areas of need will be required.

Responsibilities

• Responsible for conducting detailed review of hospital itemized bills for identification of billing and coding opportunities for all payor's claims.
• Prepare and upload documentation clearly identifying findings.
• Accurately calculate/verify the value of compliance edits 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. Savings acceptance threshold not to exceed $50,000.00
• Adhere to department billing guidelines and documentation.
• Maintain audit accuracy and productivity standards per the latest requirements.
• Perform regular audits of lower-level team members for quality assurance, providing detailed feedback and education.
• Train/Develop new team members utilizing the standard operating procedures and training manual.
• Assist team members with daily claim inquiries and difficult claim processing.
• Respond to inquiries from Client Services and Provider Services in a timely manner regarding the reacceptance/revision/reprocessing of claims, claim inquiries, and appeal reviews when necessary.
• Coordinate/Manage the set up and processing of dual acceptance claims, as well as the creation and accuracy of client facing documentation.
• Maintain awareness of and ensure adherence to Zelis standards regarding privacy.
• Assist other Zelis staff members as needed, and as requested.
• .
• JOB REQUIREMENTS:
• Technical Skills / Knowledge:
• Demonstrates solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers.
• Proficiency in training techniques aimed at conveying subject matter expertise and scaling staff to maximize savings and revenue.
• Computer proficiency and technical aptitude with the ability to utilize CMS, EncoderPro, other audit software and tools, MS Office Suite.
• Thorough knowledge of company and departmental policies and procedures.
• Independence/ Accountability:
• Maintain personal production and savings quota.
• Requires minimal daily supervisio

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