Client Policy Specialist

The Client Policy Specialist is a client facing role that is responsible for clinically interpreting and assessing client clinical and payment policy data, as well as being able to document the configuration required for the application of clinical and payment policy of Zelis edits.

This is a remote/work from home position.

KEY RESPONSIBILITIES

• Review client clinical and payment policy documents.Interpret and document the configurations to be applied to Zelis edits.Coordinate review and sign off with the Medical Director prior to implementation.
• Conduct research and analysis for medical policy items for configuration of Zelis edits; advise how they can be configured to comply with client specific clinical and payment policy.
• Translate clients medical policy to Zelis edit configurations.
• Understand and articulate medical policies; present the policies and associated edit configuration for review and acceptance by the client.
• Provide direction to internal team based on understanding of client medical policies.
• Proactively lend expertise to implementation team.
• Communicate effectively with various members of the client team (internal as well as external) to share client opportunity and limitations.
• Work with Healthcare Economics team to understand data and report impact and opportunity to client.
• Apply project management principles in initiating, creating and managing projects.
• Review and analyze client inquiries for clarity of intent; apply decisions for affected policies while maintaining information and communicating effectively with the client.
• Monitor, research, and summarize changes as client payment and medical policy changes.
• Ensure compliance with HIPAA regulations and requirements.
• Participate in any staff training as necessary.
• Maintain awareness of and ensure adherence to Zelis standards regarding privacy

Technical Skills / Knowledge:

• Demonstrates solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers.
• Proficiency in training techniques aimed at conveying subject matter expertise and scaling staff to maximize savings and revenue.
• Computer proficiency and technical aptitude with the ability to utilize CMS, Revenue Cycle Pro, other audit software and tools, MS Office Suite.
• Thorough knowledge of company and departmental policies and procedures.

PROFESSIONAL EXPERIENCE/QUALIFICATIONS

• 5-10+ years of relevant experience or equivalent combination of education & work within healthcare payers
• Extensive knowledge of reimbursement methodologies and acceptable billing practices
• Knowledge of payer reimbursement policies, state and federal regulations and applicable industry standards
• Current certified coder (CCS, CCS-P or CPC), or registered health information technician (RHIA/RHIT) , or RN, LPN with coding knowledge required
• Project management
• Experience managing internal and external relationships
• Excellent verbal & written communication skills
• Proficient in Microsoft Office, Word, Excel

COMPENSATION:

An attractive compensation package comprised of base salary, plus incentives, as well as full benefits has been created to attract outstanding candidates.