Nurse Reviewer

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 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 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 Reviewer will be primarily responsible for conducting post-service, pre-payment in-depth claim reviews based on accepted medical necessity guidelines, billing and coding rules, plan policy exclusions, and clinical or 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

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 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 including high-cost pharmaceutical and implants products utilizing all applicable tools and software, for medical appropriateness
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.
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

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.

EDUCATION:
LPN or RN required
Coding and DRG experience preferred
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 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
Working knowledge of Health Insurance, Medicare guidelines and various healthcare programs.
Clinical skills to evaluate appropriate Medical Record Coding.

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!