Job Description

Position Overview:

The Nurse Reviewer is primarily responsible for conducting post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria, billing and coding rules, plan policy exclusions, and payment errors/overpayments. Conduct review of facility and outpatient bills as it compares with medical records and coverage policies. Conduct prompt claim review to support internal inventory management to achieve greatest possible savings for clients.

Key responsibilities:

• RN or LPN required.

• Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs.

• Demonstrates expert understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers.

• 3-5 years of auditing, claims, review and/or billing experience with a health care organization or provider preferred.

• 2+ years of auditing or performing claims review in specialty pharmacy claims or specialty drugs

• Strong understanding and experience with utilizing Medicare and commercial drug reimbursement policies

• Experience with working with clients and/or payors directly preferred

• Experience with cross-functional work/collaboration for clinical projects

• Proven ability to communicate regarding clinical assignments or projects as needed

• Strong clinical assessment skills, analytical care planning and care management experience needed.

• Varied clinical experience, including Med/Surg, ICU or Emergency Medicine preferred.

• Excellent written and verbal communication skills.

• Highly organized with attention to detail.

• Payment Integrity, Coding and/or DRG experience preferred.

• Working knowledge of Health Insurance, Medicare guidelines and various healthcare programs.

Job Requirements:

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, EncoderPro, other audit software and tools, MS Office Suite

• Thorough knowledge of company and departmental policies and procedures

Independence/ Accountability:

• Maintain personal production and savings quota

• Requires minimal daily supervision

• Regularly reviews goals and objectives with supervisor

• Oversees assigned projects/claims with the ability to manage requested escalatio

• Ability to follow detailed instructions on new assignments

• Accountable for day-to-day tasks

• Professional manner and respect the confidentiality of administrative matters and files

• Ability to manage and prioritize multiple tasks

• Ability to work under pressure and meet deadlines

• Ability to withstand long periods of computer work

Problem Solving:

• Makes logical suggestions as to likely causes of problems and independently recommends solutions

• Excellent organizational skills are required to prioritize responsibilities, thus completing work in a timely fashion

• Outstanding ability to multiplex tasks as required

• Excellent project management skills

• Attention to detail and concern for impact is essential

• Excellent communication and presentation skills to effectively interface with the entire staff, and external representatives from the business, financial, legal and scientific communities

Professional Experience:

• RN or LPN required

• Coding and DRG experience preferred

• Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs

• Demonstrates strong understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers

• 3-5 years of auditing, claims, review and/or billing experience with a health care organization required

• Understanding of hospital coding and billing rules

• Demonstrates solid understanding of audit techniques

• Excellent written and verbal communication skills

• Highly organized with attention to detail

• Clinical skills to evaluate appropriate Medical Record Coding and billing accuracy

Leadership Activities:

• Provides guidance to lower level personnel.

• Regularly attends meetings and leads training sessions.

• Must be proactive to ensure proper follow up and completion of projects.

• Must maintain a professional demeanor in sensitive situations.

• Assists other departments as necessary.

Communication Skills:

• Must work well with others.

• Effectively communicate with others by giving and receiving feedback.

• Communicates ideas and information clearly.

• Must have excellent communication and presentation skills to effectively interface with the entire staff, and external representatives from the business, financial, legal and scientific communities.

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.

Zelis is modernizing the healthcare financial experience by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. This platform serves more than 750 payers, including the top 5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients.

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 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 encourage members of traditionally underrepresented communities to apply, even if you do not believe you 100% fit the qualifications of the position, including women, LGBTQIA people, people of color, and people with disabilities.

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 TalentAcquisition@zelis.com

SCAM ALERT: There is an active nationwide employment scam which is now using Zelis to garner personal information or financial scams. This site is secure, and any applications made here are with our legitimate partner. If you're contacted by a Zelis Recruiter, please ensure whomever is contacting you truly represents Zelis Healthcare. We will never asked for the exchange of any money or credit card details during the recruitment process. Please be aware of any suspicious email activity from people who could be pretending to be recruiters or senior professionals at Zelis.

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