Medicaid Pricer Regulatory Analyst

About Us

Zelis is modernizing the healthcare financial experience in the United States (U.S.) 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.

At Zelis, AI is woven into the fabric of how we work. Every associate is expected - and empowered - to partner with AI to challenge the status quo, accelerate innovation, and amplify their impact. This is a place for builders with a growth mindset who act with agility, embrace change, and use modern technology to shape smarter solutions, exceptional experiences, and the future of our industry for our clients, customers, and our culture.

Why We Do What We Do

In the U.S., consumers, payers, and providers face significant challenges throughout the healthcare financial journey. Zelis helps streamline the process by offering solutions that improve transparency, efficiency, and communication among all parties involved. By addressing the obstacles that patients face in accessing care, navigating the intricacies of insurance claims, and the logistical challenges healthcare providers encounter with processing payments, Zelis aims to create a more seamless and effective healthcare financial system.

Zelis India plays a crucial role in this mission by supporting various initiatives that enhance the healthcare financial experience. The local team contributes to the development and implementation of innovative solutions, ensuring that technology and processes are optimized for efficiency and effectiveness. Beyond operational expertise, Zelis India cultivates a collaborative work culture, leadership development, and global exposure, creating a dynamic environment for professional growth. With hybrid work flexibility, comprehensive healthcare benefits, financial wellness programs, and cultural celebrations, we foster a holistic workplace experience. Additionally, the team plays a vital role in maintaining high standards of service delivery and contributes to Zelis’ award-winning culture.

Position Overview

The Audit Analyst will be responsible for conducting thorough audits of process, ensuring compliance with Regulatory Pricer Product standards and identifying areas of improvement.

objECTIVES AND RESPONSIBILITIES:

· Perform details audits on operational processes and validate compliance with internal polies and external regulations.

· Analyze data and operational metrics to identify discrepancies, trends and areas of improvement.

· Conduct in-depth research of pricing issues, system related problems and policy and procedure challenges to confirm root cause. Recommend actions/resolutions.

· Prepare comprehensive audit reports, summarize findings and provide actionable recommendations to managements.

· Ensure adherence to regulatory and business requirements and internal controls.

· Identify areas of potential risk and develop strategies to mitigate them.

· Collaborate with varies departments to implement process improvements and enhance operational efficiency.

· Maintain accurate and up-to-date audit documentation and records.

· Provide training and support to staff on audit related matters.

• Support multiple audit projects, initiatives and tasks while adhering to deadlines.
• Maintain awareness of and ensure adherence to Zelis standards regarding privacy.

What You Will bring:

• Highly organized and results driven.
• Excellent problem solving and analytical skills.
• Ability to prioritize and manage multiple concurrent projects.
• Ability to work through others without direct supervisory responsibility within departments and across the organization.
• Understanding of pricing business rules, medical coding and medical claims.
• Understanding of the life of a claim, including adjusted/corrected claims.
• Excellent attention to detail to assess issues and resolve in a timely manner.
• Basic database skills using MS SQL.
• Ability to identify key factors and decisions that will make a project successful.
• Ability to see the big picture and learn new processes, technologies and envision how they could benefit Zelis.
• Must have excellent communication and presentation skills to effectively interface with team members.

education:

• 2 years of relevant experience or equivalent combination of education & work within healthcare payer or provider.
• Knowledge of healthcare reimbursement methodologies and acceptable billing practices.
• Knowledge of payer reimbursement policies, state and federal regulations and applicable industry standards.
• Knowledge of claims adjudication process and interpret claim editing rules.
• Certified coder (CCS, CCS-P or CPC), or registered health information technician (RHIA/RHIT), or RN, LPN with coding knowledge a plus.
• Understanding of SQL Server 2000/2005/2008 is a plus.
• Project management experience a plus.

• Excellent written, oral and presentation skills and ability to communicate complex concepts.
• Proficient in Microsoft Office, Word, Excel.

Commitment to Diversity, Equity, Inclusion, and Belonging

At Zelis, we champion diversity, equity, inclusion, and belonging in all aspects of our operations. We embrace the power of diversity and create an environment where people can bring their authentic and best selves to work. We know that a sense of belonging is key not only to your success at Zelis, but also to your ability to bring your best each day.

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.

Accessibility Support

We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability and require reasonable accommodation with any part of the application and/or interview process, please email talentacquisition@zelis.com.