Itemized Bill Review, Facility Reviewer

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 Expert Claims 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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Key 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 

Job Requirements:

Technical Skills / Knowledge:

• 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 with strong attention to detail

• Diligent research and organizational skills

• Excellent verbal and written communication skills

• Proficient in Microsoft Office, more importantly Outlook, Excel, and Word

Independence/ Accountability:

• Savings acceptance threshold not to exceed TBC $500,000.00

• Maintain individual productivity standard of 10 claims accepted per day

• Consistently meet or exceed personal …