Zelis Senior Compliance Analyst in United States
The Senior Compliance Analyst will work with the Zelis Payer Compass compliance team to further the company’s goals by researching, analyzing, documenting, and communicating rules, regulations, and procedures pertaining to public and private healthcare payment systems such as Medicare, Medicaid, TRICARE, Workers Compensation, and commercial payment systems. This position requires an in-depth knowledge of healthcare reimbursement processes and procedures including institutional, as well as, professional payment systems. Further, this position is an internal resource to staff and clients and will need to respond to both internal and external issues in an accurate and timely fashion.
Essential Duties and Functions
Research and decipher complex legal and regulatory sources regarding payment rules for public payment systems such as Medicare, Medicaid (in multiple states), TRICARE, Veteran’s Administration, and Workers Comp (also in multiple states) as well as deciphering contractual language regarding commercial payment arrangements
Draft concise documentation for payment procedures—including payment calculation logic—and interacting with the development team to refine that documentation into user stories and project plans
Perform data analysis tasks (i.e., fee schedules, provider files, base rates) using in-house or off-the-shelf software (such as Microsoft Excel)
Interact with regulators and clients to determine and document requirements
Assist with implementations, quality assurance activities, compliance audits, troubleshooting, and defect correction
Educate internal and client staff regarding payment systems and procedures
Updates internal documentation and processes as needed
Work with supporting staff to oversee one or more payment systems
Identify issues upfront and communicate clearly to team members and leadership.
Manage competing priorities and deliver quality information and analysis while adhering to deadlines
Miscellaneous responsibilities as assigned
Experience, Qualifications, Knowledge, and Skills
Bachelor’s degree or above in healthcare administration, business administration, or a related field
Minimum of five years of experience in Medicare Part A and/or Part B billing and reimbursement
Experience with Medicaid billing and reimbursement a plus
Strong close-reading and analytical skills—the ability to correctly decipher dense regulatory or procedural language
Ability to define issues, collect data, establish facts, and draw valid conclusions
Strong research and data analysis skills
Advanced Microsoft Excel skills (i.e., functions, macros, pivot tables, data validation, etc.)
Experience with writing queries a plus
A good understanding of public and private healthcare payment systems, medical claims, standard claim coding, claim editing, contracting, preferred-provider organizations, narrow networks, and other healthcare-related organizational constructs
Ability to understand in-house developed systems and identify risks with, or gaps in, those systems
Ability to prioritize multiple tasks and meet deadlines with minimal supervision
Superior verbal and written communication skills
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Sedentary work - Exerting up to 10 pounds of force occasionally, and/or a negligible amount of force frequently to lift, carry, push, pull or otherwise move objects in daily work use (laptop, monitors, et. al). Sedentary work involves sitting most of the time. Use of keyboards (typing) and exposure to computer screens occurs daily. Pleasant work environment in office locations with occasional noise or dust.
While performing the duties of this job, the employee is regularly required to stand; walk; sit; use hands; reach with hands and arms; think; and talk or hear (multi-channel, two-way communication during work hours is required).
As a leading payments company in healthcare, we guide, price, explain, and pay for care on behalf of insurers and their members. We’re Zelis in our pursuit to align the interests of payers, providers, and consumers to deliver a better financial experience and more affordable, transparent care for all. We partner with more than 700 payers, including the top-5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, over 4 million providers, and 100 million members, enabling the healthcare industry to pay for care, with care. Zelis brings adaptive technology, a deeply ingrained service culture, and a comprehensive navigation through adjudication and payment platform to manage the complete payment process.
Zelis provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
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As the leading healthcare payments company, we price, pay and explain care for payers, providers, and healthcare consumers. Zelis was founded on a belief there is a better way to determine the cost of a healthcare claim, manage payment-related data, and make the payment because more affordable and transparent care is good for all of us. We partner with over 700 payers, 1.5 million providers, and millions of members -- enabling the healthcare industry to pay for care, with care.Zelis brings adaptive technology, a deeply ingrained service culture, and an integrated pre-payment through payments platform to manage the complete payment process.