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A successful Senior Analyst will ensure a high level of quality and accuracy through benefit configuration, test execution and validation efforts while serving as a subject matter expert on benefits and claim adjudication system coding setup.
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Advanced knowledge of PBM operations, RxCLAIM claim adjudication, eligibility and benefits. Ability to manage and execute concurrent client testing for M3P, impact to ORx and plan sponsor readiness to be CMS compliant for 10/1 and 1/1, member abrasion.
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The Zelis Payments Client Service Representative is part of an upbeat and caring team responsible for addressing issues or concerns from our clients related to our products and processes. Zelis brings adaptive technology, a deeply ingrained service culture, and a comprehensive navigation through adjudication and payment platform to manage the complete payment process.
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We offer our clients competitively priced reinsurance solutions, additional capacity when needed most, expert underwriting services, insightful research and development, state-of-the-art individual cession administration and skilled claims adjudication know-how.
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Maintain close partnerships with stakeholders in sales, client experience and technology to ensure flawless handoffs and holistic client familiarity, driving OneZelis alignment. Prevent client concerns and escalations, ensure a positive client experience throughout the implementation process, address issues and challenges to maintain project deadlines and expectations around quality.
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Gathers and analyzes client requirements, assesses the benefit impact on current design and claims processing, presents to the stakeholder and/or other internal partners with benefit setup options, and advises on the best solution.
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Partner with Sales and Account Management with implementation activities from kick off to post production hand off of client. Interact and collaborate with Adjudication Partners as applicable related to implementation of mutual clients.
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To analyze Workers Compensation Claims claims on behalf of our valued clients to determine benefits due, while ensuring ongoing adjudication of claims within service expectations, industry best practices, and specific client service requirements.
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This role ensures client delight, as well as meeting and exceeding business objectives and operational metrics based on strategic goals. Strong client relationship skills including the ability to influence clients and guide them to the best possible solution.
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Builds strong, trusting team relationships within the Operations Department and across the organization, System Support, Development Support, DBA/SQL, Client Services and Quality Assurance to maintain client satisfaction.
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Claims Processing Oversight: Supervise the end-to-end claims processing operations, including intake, adjudication, and payment processes, to ensure accuracy, timeliness, and compliance. Client Services: Ensure exceptional client service standards by promptly addressing inquiries, escalations, and complaints related to claims processing, striving to achieve high levels of member satisfaction.
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Experience with adjudication processes (FirstRx preferred), analyzing benefit plan design and system application. Facilitates conversations within the team to define client intent or program setup.
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Senior Benefit Plan Configuration Analyst - Preferably Remote in the California market. We help people get the medicine they need to feel better and live well. Identifies, analyzes and presents to leadership creative solutions for process improvement activities regarding benefit configuration.
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Summary: The Client Success Manager will work independently and effectively to manage highly complex health plan clients, ensure their satisfaction and will be responsible for overseeing the project management of client release upgrades from initiation, planning, and execution.
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The Claims Analyst works with the Network Management and Client Services teams. Closely monitors and exceeds, when possible, client claim processing turnaround times (TAT). Completes revisions to repriced claims as requested by Client Services.
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