job title: IBR Reviewer(zelis)

Skill Requirements:

• CPC Certification – Preferred but not mandatory; candidates with the certification will be given an added advantage.

• Experience in Denials and Clinical Investigators profiles will be suitable for this position.

• Should have experience in Itemized Bill Reviewing

• Strong understanding of medical insurance and claims processes.

• Knowledge of medical billing and coding, payer policies, and reimbursement policies

• Excellent Communication Skills

Targeted Companies: Optum, Omega, and Cotiviti

Additional Details:

• Shift Timing: Night shift (5:30 PM to 2:30 AM)

• Work Environment: Clean room

• Work Mode: 5 days from office

• Open Positions: 4

• Experience : 3-7 Years

*Note: Please ensure that only strong and well-qualified profiles are submitted, as candidates will undergo an assessment at the final stage of the selection process.

Job Description:

At Zelis, the Itemized Bill Review Facility Reviewer I is responsible for analyzing facility inpatient and outpatient claims for Health Plans and TPA’s to ensure adherence to proper coding and billing guidelines. They will work closely with Hospital Bill Review and Concept Development staff to efficiently identify billing errors and adhere to policies and procedures for claims processing. This is a production-based role with production and quality metric goals.

Key Responsibilities:

• Conduct detailed review of hospital itemized bills for identification of billing and coding errors for all payor’s claims

• Contribute process improvement and efficiency ideas to team leaders and in team meetings

• Translate client reimbursement policies into Zelis coding and clinical concepts

• Understand payor policies and their application to claims processing

• Prepare and upload documentation clearly and precisely 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

• Maintain individual average productivity standard of 10 processed claims per day

• Consistently meet or exceed individual average quality standard of 85%

• Ability to manage a variety of claim types with charges up to $500,000

• Collaborate between multiple areas within the department as necessary

• Follow standard procedures and suggest areas of improvement

• 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.

Skills, Knowledge, and Experience:

• CPC credential preferred

• 1 – 2 years of applicable healthcare experience preferred

• Graduate

• 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

• Ability to manage and prioritize multiple tasks

• Attention to detail is essential

• Accountable for day-to-day tasks

• Excellent verbal and written communication skills

• Proficient in Microsoft Office Suite