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Nurse Reviewer

Nursing Jobs


Mid Level


Not defined

05 Jul → 04 Aug


Bedminster, NJ, USA

About Company

Zelis is a healthcare and financial technology growth company and market-leading provider of claims cost and payments optimization solutions to price, pay and explain healthcare claims. Zelis delivers integrated network analytics and access, payment integrity, electronic payments and claims communications for payers, healthcare providers and consumers in the medical, dental and workers' compensation markets nationwide.
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Job Description

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 the greatest possible savings for clients.

Business-related Travel:
Travel requirements to (primarily) domestic destinations should not exceed 10%.
“We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.”

Job 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.

Requirements / Qualifications

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

How To Apply

Apply through GoRemotely.

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