Nurse Reviewer
1 week ago
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
- RN or LPN required.
- 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 or provider preferred.
- 2+ years of auditing or performing claims review in specialty pharmacy claims or specialty drugs
- Strong understanding and experience with utilizing Medicare and commercial drug reimbursement policies
- Experience with working with clients and/or payors directly preferred
- Experience with cross-functional work/collaboration for clinical projects
- Proven ability to communicate regarding clinical assignments or projects as needed
- Strong clinical assessment skills, analytical care planning and care management experience needed.
- Varied clinical experience, including Med/Surg, ICU or Emergency Medicine preferred.
- Excellent written and verbal communication skills.
- Highly organized with attention to detail.
- Payment Integrity, Coding and/or DRG experience preferred.
- Working knowledge of Health Insurance, Medicare guidelines and various healthcare programs.
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
- Maintain personal production and savings quota
- Requires minimal daily supervision
- Regularly reviews goals and objectives with supervisor
- Oversees assigned projects/claims with the ability to manage requested escalatio
- Ability to follow detailed instructions on new assignments
- Accountable for day-to-day tasks
- Professional manner and respect the confidentiality of administrative matters and files
- Ability to manage and prioritize multiple tasks
- Ability to work under pressure and meet deadlines
- Ability to withstand long periods of computer work
- Makes logical suggestions as to likely causes of problems and independently recommends solutions
- Excellent organizational skills are required to prioritize responsibilities, thus completing work in a timely fashion
- Outstanding ability to multiplex tasks as required
- Excellent project management skills
- Attention to detail and concern for impact is essential
- Excellent communication and presentation skills to effectively interface with the entire staff, and external representatives from the business, financial, legal and scientific communities
- RN or LPN required
- Coding and DRG experience preferred
- Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs
- Demonstrates strong 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
- Clinical skills to evaluate appropriate Medical Record Coding and billing accuracy
- Provides guidance to lower level personnel.
- Regularly attends meetings and leads training sessions.
- Must be proactive to ensure proper follow up and completion of projects.
- Must maintain a professional demeanor in sensitive situations.
- Assists other departments as necessary.
- Must work well with others.
- Effectively communicate with others by giving and receiving feedback.
- Communicates ideas and information clearly.
- Must have excellent communication and presentation skills to effectively interface with the entire staff, and external representatives from the business, financial, legal and scientific communities.
Zelis is modernizing the healthcare financial experience 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 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts – driving real, measurable results for clients.
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.
-
Clinical Review Nurse
4 weeks ago
Atlanta, United States Centene Corporation Full timeYou could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.Position Purpose Performs concurrent reviews, including determining member's...
-
Utilization Review Nurse
2 months ago
Atlanta, Georgia, United States Sonder Health Plans, Inc. Full timeJob Description:The Utilization Review Nurse's role is to ensure that health care services are administered with quality, cost efficiency, and within compliance. By continuously reviewing and auditing member treatment records, the utilization review nurse will ensure members do not receive unnecessary procedures, ineffective treatment, or experience...
-
Utilization Review Nurse
4 weeks ago
Atlanta, United States Sonder Health Plans, Inc. Full timeJob Description: The Utilization Review Nurse's role is to ensure that health care services are administered with quality, cost efficiency, and within compliance. By continuously reviewing and auditing member treatment records, the utilization review nurse will ensure members do not receive unnecessary procedures, ineffective treatment, or experience...
-
Utilization Review Nurse
3 months ago
Atlanta, United States Sonder Health Plans Full timeJob DescriptionJob DescriptionJob Description:The Utilization Review Nurse’s role is to ensure that health care services are administered with quality, cost efficiency, and within compliance. By continuously reviewing and auditing member treatment records, the utilization review nurse will ensure members do not receive unnecessary procedures, ineffective...
-
Nurse Reviewer
5 days ago
Atlanta, United States Zelis Full timePosition OverviewThe 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...
-
Nurse Reviewer
1 week ago
Atlanta, United States Zelis Full timePosition OverviewThe 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...
-
Medical Review Nurse
7 days ago
Atlanta, United States Pyramid Consulting, Inc Full timeImmediate need for a talented Medical Review Nurse - RN This is a 02+ Months Contract opportunity with long-term potential and is located in North Carolina, NC(Remote) . Please review the job description below and contact me ASAP if you are interested. Job ID:24-40151 Pay Range: $35 - $39/hour. Employee benefits include, but are not limited to, health...
-
Medical Review Nurse
2 weeks ago
Atlanta, United States Pyramid Consulting, Inc Full timeImmediate need for a talented Medical Review Nurse - RN This is a 02+ Months Contract opportunity with long-term potential and is located in North Carolina, NC(Remote) . Please review the job description below and contact me ASAP if you are interested. Job ID:24-40151 Pay Range: $35 - $39/hour. Employee benefits include, but are not limited to, health...
-
Clinical Review/Utilization Nurse
2 months ago
Brookhaven, GA, United States Children's Healthcare of Atlanta Full timeNote: If you are CURRENTLY employed at Children's and/or have an active badge or network access, STOP here. Submit your application via Workday using the Career App (Find Jobs).Work ShiftVariableWork Day(s)VariableShift Start Time8:00 AMShift End Time4:00 PMWorker Sub-TypePRNChildren’s is one of the nation’s leading children’s hospitals. No matter the...
-
Clinical Review Nurse I
2 months ago
Atlanta, Georgia, United States Elevance Health Full timeClinical Review Nurse I - Medicare Part ANational Government Services is a proud member of Elevance Health's family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs.Location:This is a virtual position and preferred candidates reside within 50 miles...
-
Utilization Review Nurse
2 days ago
Atlanta, Georgia, United States Sidecar Health Full timeAbout the RoleAs a Utilization Review Nurse at Sidecar Health, you will play a critical role in evaluating the medical necessity and quality of healthcare services for our members. This involves reviewing medical records, ensuring compliance with established clinical guidelines and policies, and collaborating with healthcare providers to gather additional...
-
Medical Record Reviewer
7 days ago
Atlanta, Georgia, United States Spectraforce Technologies Full timeJob Title: HEDIS Nurse Abstractor SpecialistJob Summary:Spectraforce Technologies is seeking a highly skilled HEDIS Nurse Abstractor Specialist to join our team. As a HEDIS Nurse Abstractor Specialist, you will be responsible for reviewing medical records, abstracting pertinent data, and entering it into a specified database to support HEDIS reporting.Key...
-
Medical Necessity Reviewer
7 days ago
Atlanta, Georgia, United States Piedmont Healthcare Corporate Full timeJob SummaryPiedmont Healthcare Corporate is seeking a skilled Clinical Appeals Specialist to join our team. As a key member of our appeals process, you will be responsible for reviewing and analyzing patient medical records to draft effective narratives for Medicare and Medicaid appeals documentation and briefs.Key ResponsibilitiesConduct detailed reviews of...
-
Medical Necessity Reviewer
7 days ago
Atlanta, Georgia, United States Piedmont Healthcare Corporate Full timeAbout the Role:Piedmont Healthcare Corporate is seeking a skilled Clinical Appeals Specialist to join our team. As a key member of our appeals process, you will be responsible for reviewing and analyzing patient medical records to draft effective narratives for Medicare and Medicaid appeals documentation and briefs.Key Responsibilities:Conduct detailed...
-
Medical Necessity Reviewer
7 days ago
Atlanta, Georgia, United States Piedmont Full timeJob Summary:Piedmont is seeking a highly skilled Clinical Appeals Specialist to join our team. As a Clinical Appeals Specialist, you will be responsible for reviewing and analyzing patient medical records to draft effective narratives for Medicare and Medicaid appeals documentation and briefs.Key Responsibilities:Conduct detailed reviews of patient medical...
-
Utilization Review Nurse
2 weeks ago
Bremen, IN, United States Neuropsychiatric Hospitals Full timeAbout Us:HEALING THE BODY AND MINDFounded fifteen (15) years ago, NeuroPsychiatric Hospital is the largest hospital system in the nation providing care to patients with both neurological and medical needs. We are unique in that we serve a population which others have been previously been unable to, largely due the patient’s underlying medial issues. Our...
-
Healthcare Claims Review Specialist
2 weeks ago
Atlanta, United States KARNA LLC Full timePosition OverviewAre you dedicated to enhancing healthcare outcomes? KARNA LLC is seeking a skilled Medical Claims Review Nurse to contribute to our mission of supporting individuals affected by significant health events. This role is pivotal in ensuring that claims are meticulously reviewed for medical necessity and in addressing provider appeals...
-
Clinical Review Specialist
7 days ago
Atlanta, Georgia, United States Sonder Health Plans Full timeJob Description:The Clinical Review Specialist role at Sonder Health Plans is to ensure that healthcare services are administered with quality, cost efficiency, and within compliance.By continuously reviewing and auditing member treatment records, the Clinical Review Specialist will ensure members do not receive unnecessary procedures, ineffective treatment,...
-
Leesburg, FL, United States UF Health-Central Florida Full timeOverview UF Health Leesburg Hospital has been serving the health care needs of our community for 58 years. The hospital offers advanced cardiac care including one of the largest cardiothoracic surgery programs in the state. The American College of Cardiology has recognized UF Health Leesburg Hospital for its demonstrated expertise and commitment in...
-
Leesburg, FL, United States UF Health-Central Florida Full timeOverview UF Health Leesburg Hospital has been serving the health care needs of our community for 58 years. The hospital offers advanced cardiac care including one of the largest cardiothoracic surgery programs in the state. The American College of Cardiology has recognized UF Health Leesburg Hospital for its demonstrated expertise and commitment in treating...
