Zelis Healthcare, LLC
Client Policy Specialist
Zelis Healthcare, LLC, Orlando, Florida, us, 32885
POSITION OVERVIEW:The Client Policy Specialist is a client-facing role that will act as the subject matter expert (SME) as it pertains to Zelis editing product in support of the growth and expansion of assigned clients. The Client Policy Specialist will lead the sales overview discussion of new/existing opportunities for the Zelis editing product during client meetings in partnership with the Client Management team. This includes, but is not limited to, review of client data to identify pre/post-production edit volume and savings, edit trends, outliers while providing rationale and potential customization options to ensure Zelis edit logic is aligned with internal policies of assigned clients and their specific Lines of Business. The Client Policy Specialist will ensure day-to-day activities of assigned team aligns with the overall mission and adherence to best practice policies as defined by the organization.ESSENTIAL FUNCTIONS
:Demonstrate an expert level understanding of Zelis editing products with an ability to clearly articulate correct coding and claim adjudication guidelines, interpretation of client policies and present Zelis edits/editing suites to assigned clients.Primary contact for Client Manager to support the retention and expansion of Zelis Editing Products for assigned clients.Ability to work day-to-day with autonomy. Individual contributor as it pertains to assigned clients but works well with CPS team and provides guidance and asks questions as needed.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.Ability to recommend editing adjustments and modifications as needed to product and to the client.Includes and identifies 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.Proactively monitor, research and present edit customizations to clients to ensure that all customizations are up-to-date and valid.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.Ensure compliance with HIPAA regulations and requirements.PROFESSIONAL EXPERIENCE
: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
:Travel requirements to (primarily) domestic destinations should not exceed 10%.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.Location and Workplace Flexibility:
We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture and all of our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies.
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:Demonstrate an expert level understanding of Zelis editing products with an ability to clearly articulate correct coding and claim adjudication guidelines, interpretation of client policies and present Zelis edits/editing suites to assigned clients.Primary contact for Client Manager to support the retention and expansion of Zelis Editing Products for assigned clients.Ability to work day-to-day with autonomy. Individual contributor as it pertains to assigned clients but works well with CPS team and provides guidance and asks questions as needed.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.Ability to recommend editing adjustments and modifications as needed to product and to the client.Includes and identifies 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.Proactively monitor, research and present edit customizations to clients to ensure that all customizations are up-to-date and valid.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.Ensure compliance with HIPAA regulations and requirements.PROFESSIONAL EXPERIENCE
: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
:Travel requirements to (primarily) domestic destinations should not exceed 10%.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.Location and Workplace Flexibility:
We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture and all of our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies.
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