Remote Nurse Auditor

Zelis Healthcare - Field (30+ days ago)2.8

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!


Zelis Healthcare is an information technology company which utilizes an end-to-end technology platform to fulfill the claims cost management and payments needs of healthcare payors including large and medium-sized health plans, TPAs, Taft-Hartley Plans, providers, and individuals. The company provides a comprehensive portfolio of network management, claims integrity, payment remittance solutions and analytical services for medical, dental and workers' compensation claims to over 500 payor clients. Additionally, the company delivers electronic payments and explanation of payments to over 200,000 healthcare providers and serves individuals with provider lookup and medical referral services.

Position Overview

The Nurse Auditor will be primarily responsible for conducting in-depth and its 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. Maintaining timely professional communication with Providers, internal team and management to achieve savings for clients.

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.

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

Sufficient clinical experience in medical surgical and or critical care

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.

LPN or RN required

Travel requirements to (primarily) domestic destinations should not exceed 5%.

A standard work week exists but with the understanding that additional time/effort outside of the usual parameters can/will occur based upon the overall needs of the integration, where deadlines exist and when necessary due to the needs of the integration team.

A standard business environment exists with moderate noise levels.

Ability to lift and move approximately thirty (30) pounds on a non-routine basis.

Ability to sit for extended periods of time.