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Nurse Reviewer

Sapphire Digital

Sapphire Digital

Multiple locations
Posted on Tuesday, February 6, 2024

Position Overview

At Zelis, the Nurse Reviewer is 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.

Key Responsibilities

  • Conduct review of facility and outpatient bills as it compares with medical records and coverage policies

  • Perform prompt claim review to support internal inventory management to achieve greatest possible savings for clients

  • Relying on clinical experience, follow care plans and treatment plans in reviewing each patient record thoroughly to look for billing appropriateness or other misalignments

  • Work collaboratively with a team of professionals and ask questions for clarity when needed

Required Qualifications

  • RN or LPN

  • Clinical assessment, analytical care planning and care management experience

  • Experience with Health Insurance, Medicare guidelines and/or other healthcare programs

Preferred Qualifications

  • Expert understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers

  • 3+ years of auditing, claims, review and/or billing experience with a health care organization or provider

  • Prior leadership experience

  • Understanding of hospital coding and billing rules

  • Varied clinical experience, including Med/Surg, ICU or Emergency Medicine

  • Payment Integrity, Coding and/or DRG experience

  • Clinical skills to evaluate appropriate Medical Record Coding

#LI-RZ1

As a leading payments company in healthcare, we guide, price, explain, and pay for care on behalf of insurers and their members. We’re Zelis in our pursuit to align the interests of payers, providers, and consumers to deliver a better financial experience and more affordable, transparent care for all. We partner with more than 700 payers, including the top-5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, over 4 million providers, and 100 million members, enabling the healthcare industry to pay for care, with care. Zelis brings adaptive technology, a deeply ingrained service culture, and a comprehensive navigation through adjudication and payment platform to manage the complete payment process.

Commitment to Diversity, Equity, Inclusion, and Belonging
At Zelis, we champion diversity, equity, inclusion, and belonging in all aspects of our operations. We embrace the power of diversity and create an environment where people can bring their authentic and best selves to work. We know that a sense of belonging is key not only to your success at Zelis, but also to your ability to bring your best each day.

Equal Employment Opportunity
Zelis is proud to be an equal opportunity employer. All applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

We encourage members of traditionally underrepresented communities to apply, even if you do not believe you 100% fit the qualifications of the position, including women, LGBTQIA people, people of color, and people with disabilities.

Accessibility Support

We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email TalentAcquisition@zelis.com

SCAM ALERT: There is an active nationwide employment scam which is now using Zelis to garner personal information or financial scams. This site is secure, and any applications made here are with our legitimate partner. If you’re contacted by a Zelis Recruiter, please ensure whomever is contacting you truly represents Zelis Healthcare. We will never asked for the exchange of any money or credit card details during the recruitment process. Please be aware of any suspicious email activity from people who could be pretending to be recruiters or senior professionals at Zelis.