Manager, Configuration and Coding Compliance

COMPANY BACKGROUND/CULTURE

Zelis Healthcare is a market-leading healthcare technology company providing integrated healthcare cost management and payments solutions including network analytics and design, network access and cost management, claims cost management and electronic payments to payers, healthcare providers and consumers in the medical, dental and workers’ compensation markets nationwide. Zelis Healthcare is backed by Parthenon Capital Partners.

Position Overview

The Manager Configuration and Coding Compliance is a key role responsible for partnering with the Sr. Director Configuration and Coding Compliance to manage projects around the build out of the claims edit platform for physician and facility claims. Will work closely, as needed, with Ops, Sales & IT departments in the development and maintenance of the current product as it relates to scalability, functionality and initiatives imperative to growth.

KEY RESPONSIBILITIES

Will support and lead, as assigned, projects surrounding the build out of the Zelis Claims Editing Engine including but not limited to the edit rules engine, user interface, expansion of the client facing web portal, etc.

Partner with Senior Director for research and development process of building edits, planning for development and phases for production

Assist with product scope and ensure capabilities align with all lines of business for payors, including Group Health, Medicare & Medicaid

Work closely with Zelis teams in the creation of business models applicable to Claims Editing for Medicare & Medicaid payors

Conduct research and analysis for medical policy items for configuration of Zelis edits; work with Senior Director to determine how they can be configured to comply with client specific clinical and payment policy.

Work with Healthcare Economics team, as assigned, to understand data and report impact for determination of ROI and action steps.

Review and analyze complex inpatient, outpatient, and practitioner billing for medical appropriateness of treatment; analyze charges of various revenue centers with consideration to patient diagnosis, procedures, age and facility type including any additional information perceived as potentially helpful for new edit creation, updating or expanding existing edits

Monitor, research, and track/summarize changes as client payment and medical policy changes.

Partner with IT and operations to streamline processes, as well as create or enhance report and tool impacting the creation of new edits or revision/updating of existing edits, including the identification of requirements/functionality and user acceptance testing.

Develop a research plan, priority and timeline for identified potential edit expansion opportunities

Ensure compliance with HIPAA regulations and requirements.

Maintain awareness of and ensure adherence to Zelis standards regarding privacy.

professional experience/qualifications (TOP 3-5 SKILLS DESIRED)

7+ years of relevant experience or equivalent combination of education & work within healthcare payers

Extensive knowledge of reimbursement methodologies and acceptable billing practices

Knowledge of payer reimbursement policies, state and federal regulations and applicable industry standards

Current certified coder (CCS, CCS-P or CPC), or registered health information technician (RHIA/RHIT), or RN, LPN with coding knowledge required

Project management

Experience managing internal and external relationships

Excellent verbal & written communication skills

Proficient in Microsoft Office, Word, Excel

EDUCATION:

Bachelor’s Degree Preferred

COMPENSATION:

An attractive compensation package as well as comprehensive benefits plans are available to attract outstanding candidates.