Expert Claims Product Analyst; Concept Ideation

Position: Expert Claims Product Analyst (Concept Ideation)
At Zelis, we Get Stuff Done. So, let’s get to it! A Little About UsZelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts – driving real, measurable results for clients.

At Zelis, AI is woven into the fabric of how we work. Every associate is expected - and empowered - to partner with AI to challenge the status quo, accelerate innovation, and amplify their impact. This is a place for builders with a growth mindset who act with agility, embrace change, and use modern technology to shape smarter solutions, exceptional experiences, and the future of our industry for our clients, customers, and our culture.

A Little About You You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are.

Position Overview The Senior Concept Ideation Analyst, Bill Review role is responsible for development and delivery of initiatives focused on bill review content management. The Ideation Team researches and produces new bill review content as well as enhances existing bill review content using sources such as ICD-10, AHA, AMA, CPT, AAPC, CMS and/or clinical research sources.

This role partners closely with the team in producing clinical content for bill reviews of facility claims including support for communication and documentation. They will work closely with Operations and Product teams in the development and maintenance of the content as it relates to scalability, functionality, and initiatives imperative to growth. The primary focus will be concept development for DRG Coding and Clinical Validation (MS and APR) and also includes Itemized Bill Review (I ).

Key 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 I  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

Key Qualifications Current, active CIC or CCS or equivalent credentialing is required RN or LPN with coding…