Nurse Auditor

Zelis Payments - Field

Full-time
Zelis is a healthcare information technology company and market-leading provider of end-to-end healthcare claims cost management and payment solutions.

Inc.5000 award winner: One of the fastest growing privately held companies in the US!

Ranked #1 by NJ Biz as the Fastest Growing Company in NJ!

COMPANY BACKGROUND/CULTURE

Zelis Healthcare is a mid-cap healthcare technology growth company and market-leading provider of integrated healthcare cost management and payments solutions including network analytics, network access, network cost management, payment integrity and electronic payments to payers, healthcare providers and consumers in the medical, dental and workers' compensation markets nationwide. Zelis Healthcare is backed by Parthenon Capital Partners. www.zelis.com

OUR ZELIS PURPOSE

We founded Zelis to help control the rising cost of healthcare and make healthcare more affordable for all of us.

POSITION OVERVIEW

The Nurse Auditor will be primarily responsible for conducting in-depth audits based on accepted billing and coding rules, plan policy exclusions, clinical or payment errors/overpayments. Conduct review of facility bills as it compares with medical records and coverage policies. Maintain timely professional communication with Providers, internal team and management to achieve savings for clients.

KEY RESPONSIBILITIES

Review itemized bill for medical appropriateness and billing inconsistencies by performing a line by line clinical review of claim.
Complete preliminary review of itemized bill and request medical records as needed to verify audit findings
Document in CMS all aspect of audits including uploading all provider communications, clinical and/or financial research
Submit Explanation of Audit to providers based on audit findings and secure a corrected claim or Letter of Agreement based on audit findings and financial benchmarks
Research new/unfamiliar surgical procedures as needed via web, and other research tools provided and recommend claims for Peer Review
Research specialty items like high-cost pharmaceutical and implants products utilizing all applicable tools and software, for medical appropriateness and recommend claims for Peer review.
Accountable for daily management of assigned claims, maintain claim report adhering to client turnaround time, and department Standard Operating Procedures
Prepare audit summaries as required based on audit results or by client request.
Non-accepting of claims based on assigned threshold after a thorough and complete audit as defined by department quality standards.
Maintain personal production and savings quota.
Recommend new methods to improve departmental procedures.
Maintain awareness of and ensure adherence to ZELIS standards regarding privacy.
PROFESSIONAL EXPERIENCE/QUALIFICATIONS

2-5 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, identification of revenue opportunities and financial negotiation with providers
Sufficient clinical experience in medical surgical and or critical care preferred
Excellent written and verbal communication skills
Highly organized with attention to detail
Working knowledge of Health Insurance, Medicare guidelines and various healthcare programs.
Clinical skills to evaluate appropriate Medical Record Coding.

EDUCATION:
Active LPN or RN license required.

COMPENSATION:
An attractive compensation package comprised of base salary, plus incentives, as well as full benefits has been created to attract outstanding candidates.

OUR BIG 8 ZELIS VALUES

We take personal accountability
We look for a better way
We serve each other and are always there to help
We act level-less
We use humor
We develop serious expertise
We act with integrity
We celebrate
Thank you for your interest in the Zelis team!