Client Policy Specialist

5 days ago

Saint Albans, Vermont, United States Zelis Healthcare Full time
Job Title: Client Policy Specialist

Job Summary:

The Client Policy Specialist will serve as the subject matter expert for Zelis editing products, providing expert-level understanding and articulation of correct coding and claim adjudication guidelines, interpretation of client policies, and presentation of Zelis edits/editing suites to assigned clients.

Key Responsibilities:

  • Proactively partner with Zelis assigned clients to assist in questions, concerns, and provide explanations regarding editing logic, CMS rules and regulations, and assist in client operational efficiencies.
  • Recommend editing adjustments and modifications as needed to product and to the client.
  • Identify individual stakeholders for client meetings, needs, and solutions.
  • Schedule internal stakeholder meetings for new edit offerings for assigned clients.
  • Builds relationships internally with collaborative partners and follows processes well.
  • Proactively partner with Client Policy Integration Director for input regarding Pre-Stakeholder meetings to validate pre-production data and client selection based on edit volume/potential savings opportunity.
  • Demonstrate expertise in ability to document root-cause analysis of identified client editing issues for escalation to the appropriate Zelis internal team for resolution and communication to the client.
  • Proactively monitor, research, and summarize changes to client payment policy during ongoing scheduled client meetings while partnering with Client Policy Team to ensure awareness of updates and revisions to Zelis Edits.
  • Assists in ongoing process improvement and automation.
  • Proactively escalate identified Zelis Editing Product issues utilizing all tools and resources to document and resolve issue.
  • Effectively collaborate with the Zelis Editing Product team as it pertains to editing solutions, new edit releases, and product issues.
  • Proactively partner with Product and Product Analytics team to obtain impact analysis with claim level details for production edits for all assigned clients to support upsell of existing/new production edit opportunities.
  • Partner with Client Integration Specialist and Implementation teams to support the implementation of the Zelis Edit Products for new/existing clients which includes but is not limited to edit presentation, interpreting client policies, provide guidance for requested client customizations and support testing and client 'go-live'.
  • Effectively partner with Edit Configuration and Claims Edit Validation Team to confirm client selected edit package set up with various lines of business (when applicable), interpret intent of client requested customizations, confirm configuration of requested customizations, and support post-production validation of selected client approved edit and newly deployed edits.

Requirements:

  • 3 years of relevant experience or equivalent combination of education and work experience with healthcare payers, third party administrators, and health plans.
  • Bachelor's degree preferred.
  • Current certified coder (AAPC or AHIMA) or Registered Health Information (RHIA/RHIT) certifications required.
  • Extensive knowledge of correct coding and industry standard claim adjudication guidelines and policies.
  • Extensive knowledge and ability to translate coding and adjudication guidelines, policies and references into edit policies and rules.
  • 3 years minimum client facing and/or provider facing experience which includes but is not limited to conducting product overview and sales workshops.
  • Extensive experience in managing internal/external relationships with strong Project Management skills.
  • Excellent verbal & written communication skills.
  • Proficient in Microsoft Office suite (Word, Excel, Power Point etc.).
  • Proficient in JIRA.

Work Environment:

A standard work week exists but with the understanding that additional time/effort outside of the usual parameters can/will occur based upon the overall needs of the integration, where deadlines exist and when necessary due to the needs of the integration team.

A standard business environment exists with moderate noise levels.

Ability to lift and move approximately thirty (30) pounds on a non-routine basis.

Ability to sit for extended periods of time.

Language: English

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