Nurse Reviewer

Job Description

About Us Zelis is modernizing the healthcare financial experience in the United States (U.S.) 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 health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers in the U.S. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts—driving real, measurable results for clients. Why We Do What We Do In the U.S., consumers, payers, and providers face significant challenges throughout the healthcare financial journey. Zelis helps streamline the process by offering solutions that improve transparency, efficiency, and communication among all parties involved. By addressing the obstacles that patients face in accessing care, navigating the intricacies of insurance claims, and the logistical challenges healthcare providers encounter with processing payments, Zelis aims to create a more seamless and effective healthcare financial system. Zelis India plays a crucial role in this mission by supporting various initiatives that enhance the healthcare financial experience. The local team contributes to the development and implementation of innovative solutions, ensuring that technology and processes are optimized for efficiency and effectiveness. Beyond operational expertise, Zelis India cultivates a collaborative work culture, leadership development, and global exposure, creating a dynamic environment for professional growth. With hybrid work flexibility, comprehensive healthcare benefits, financial wellness programs, and cultural celebrations, we foster a holistic workplace experience. Additionally, the team plays a vital role in maintaining high standards of service delivery and contributes to Zelis’ award-winning culture. 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 Conduct reviews of many claim types by applying a series of audit techniques to identify areas with savings potential Review and validate charges against medical documentation to unsure billing accuracy Contact medical providers via phone or email and request a review of billing inconsistencies Document tracking and claim review notes that illustrate progress and final outcome on every claim Manage a report of 25+ claims with the ability to prioritize according to client stipulations at all times Maintain personal production metrics and quality assurance scores consistently Communicate claim inquires and client needs to Team Lead and leadership Maintain awareness of and ensure adherence to Zelis standards regarding privacy Job Requirements Current RN/LPN license required Varied clinical experience, including Med/Surg, ICU or Emergency Medicine required Understanding of hospital coding and billing rules or, experience in medical claims review with an understanding of audit techniques and identification of revenue opportunities preferred Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs preferred Excellent communication and presentation skills to effectively interact directly with providers and team members Exceptional organizational skills Proficient knowledge of Microsoft Outlook, Word, and Excel Proficient in basic mathematical calculations Detailed-oriented and able to work in a fast-paced environment Ability to withstand long period of computer work while utilizing multiple computer screens at one time Work Environment 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. Show more Show less