At Zelis, we Get Stuff Done. So, let’s get to it!
A Little About Us
Zelis 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.
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 CPC/CCS Senior Edit Resolution Analyst will handle highly complex grievance and appeal cases and serves as a subject matter expert within the Resolution team. The position operates with significant autonomy, provides guidance to junior staff, and contributes to the development of SOPs and process optimization initiatives.What You’ll Do:
Manage escalated and high-risk grievance and appeal cases requiring advanced regulatory knowledge and critical thinking to ensure timely and compliant resolution.
Serve as a resource for complex inquiries from peers and leadership; interpret regulatory changes and advise on operational impacts.
Lead or contribute to the creation and refinement of SOPs, job aids, and training materials to ensure alignment with evolving regulations and organizational goals.
Provide structured guidance and coaching to junior associates, fostering skill development and adherence to quality standards.
Partner with other teams to address systemic issues, mitigate risks, and implement corrective actions.
Identify opportunities for automation, workflow redesign, and efficiency improvements; present recommendations to leadership.
Conduct peer reviews and audits of case handling to ensure accuracy, compliance, and consistency across the team.
Participate in departmental projects and initiatives aimed at improving grievance and appeals operations and member experience.
Serve as a subject matter expert on regulatory compliance and dispute resolution.
Analyze data to identify trends and recommend systemic improvements.
Drive innovation in resolution practices to enhance member experience and compliance.
What You’ll Bring to Zelis:
CPC or CCS or equivalent credentials required
3+ yrs related coding experience
Associates degree preferred
Requires proficiency using AI tools skillfully with an understanding of how to develop/create intelligent prompts and/or agents
Advanced knowledge of grievance and appeals handling in healthcare
Proven ability to coach and mentor junior staff
Experience in SOP development and process optimization
Strong problem-solving and communication skills
Ability to manage elevated and complex cases with minimal supervision
Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future.
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 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.
Equal Employment Opportunity
Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment 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.
We welcome applicants from all backgrounds and encourage you to apply even if you don’t meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all.
Accessibility Support
We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email [email protected].
Disclaimer
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.
Top Skills
What We Do
As a leading healthcare payments company, we price, explain and pay for care on behalf of 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.
