Senior Claims Content & DRG Ideation Analyst

Zelis Healthcare, LLC; Morris Township (NJ); Hybrid; USD 105,000 - 133,000; Full time

Benefits offered by this job

401k with employer match

Flexible paid time off

Holidays

Parental leaves

Health benefits

Job summary

Zelis is a healthcare fintech leader delivering bill review and clinical validation at scale. The Senior Concept Ideation Analyst will develop and deliver new bill review content using ICD-10, CPT, CMS and other sources, partnering with Operations and Product to enhance scalability and impact.

Focus is on DRG coding concepts and APR/MS validations plus Itemized Bill Review. You will communicate findings, educate teams, and drive content quality, privacy, and automation improvements across Zelis’

Qualifications

• Active CIC or CCS or equivalent credentialing is required.
• RN or LPN with coding certification, or RHIA/RHIT with at least 6–8 years experience.
• Experience with MS-DRG/APR-DRG coding and compliance required.
• Experience performing regulatory research from multiple sources, formulating an opinion, and presenting findings in an organized, concise manner.
• Knowledge of National Medicare and Medicaid regulations.
• Knowledge of payer reimbursement policies.
• Creative problem-solving skills, leveraging insights and input from other parts of an organization.
• Ability to leverage reporting tools to research claim data, trending and analysis for concept ideation processes.
• Understanding of JIRA/Confluence recommended.
• Strong organization and project/process management skills.

Responsibilities

• Serve as subject matter expert for the Ideation Team on day-to-day activities including troubleshooting and review for data accuracy.
• Review provider disputes for DRG and IBR and submit explanation of dispute rationale back to providers based on dispute findings within the designated timeframe to ensure client turnaround times are met.
• Serve as a subject matter expert for content and bill reviews and provide support where needed for inquiries and research requests.
• Create and present education to Operations team and CMO along with potentially other departments on new and updated concepts, review guidelines, and dispute findings.
• Research and analysis of content for Itemized Bill Review and DRG Validation.
• Use of strong coding and industry knowledge to create and maintain bill review content, including but not limited to DRG Reviewer Rationales, DRG Clinical Validation Policies, and Dispute Rationales.
• Perform regulatory research from multiple sources to keep abreast of compliance enhancements and additional bill review opportunities.
• Analysis of data to assess impact for content related issues or defects. Contribute to product alerts and partner with Product Management on notifications.
• Utilize the most up-to-date approved Zelis medical coding sources for bill review maintenance and development.
• Partner with other areas to assess and communicate impact to the business for additions, changes, or updates as it relates to content and bill review updates.
• Communicate and partner with CMO and members of Operations or Product teams regarding important changes, issues, and trends.
• Ensure adherence to quality assurance guidelines.
• Monitor, research, and summarize trends, coding practices, and regulatory changes.
• Provide recommendations for enhancements or trends relating to content expansion, automation, and efficiencies.
• Actively contribute new ideas and support ad hoc projects, including time-sensitive requests.
• Collaborate with Sales, Marketing and Product on updating bill review artifacts.
• Maintain awareness of and ensure adherence to Zelis standards regarding privacy.

Skills

CIC/CCS credential

RN/LPN coding cert

DRG/APR-DRG coding

Regulatory research

Payer reimbursement knowledge

JIRA/Confluence

Data analysis & reporting tools

Education

RN/LPN with coding cert or RHIA/RHIT w/ 6–8 yrs exp

Bachelor’s in health info/related field

Tools

JIRA/Confluence

Job description

Zelis is a healthcare fintech leader delivering bill review and clinical validation at scale. The Senior Concept Ideation Analyst will develop and deliver new bill review content using ICD-10, CPT, CMS and other sources, partnering with Operations and Product to enhance scalability and impact.

Focus is on DRG coding concepts and APR/MS validations plus Itemized Bill Review. You will communicate findings, educate teams, and drive content quality, privacy, and automation improvements across Zelis’