Nurse Auditor

2 weeks ago

Atlanta, Georgia, United States Zelis Full time
Job Summary

The Nurse Reviewer will be responsible for conducting in-depth claim reviews based on accepted medical guidelines and clinical criteria, billing and coding rules, plan policy exclusions, and payment errors/overpayments. This role requires a strong understanding of audit techniques, identification of revenue opportunities, and financial negotiation with providers. The ideal candidate will have 3-5 years of auditing, claims, review, and/or billing experience with a healthcare organization or provider.

Key Responsibilities
  • Conduct post-service, pre or post payment claim reviews based on accepted medical guidelines and clinical criteria.
  • Review 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.
  • Develop and implement audit plans to identify revenue opportunities and optimize payment integrity.
  • Collaborate with cross-functional teams to ensure compliance with regulatory requirements and company policies.
  • Provide guidance to lower-level personnel and lead training sessions as needed.

Requirements
  • RN or LPN required.
  • 3-5 years of auditing, claims, review, and/or billing experience with a healthcare organization or provider preferred.
  • Strong understanding of audit techniques, identification of revenue opportunities, and financial negotiation with providers.
  • Excellent written and verbal communication skills.
  • Highly organized with attention to detail.
  • Ability to work under pressure and meet deadlines.

What We Offer
  • A dynamic and collaborative work environment.
  • Opportunities for professional growth and development.
  • A competitive salary and benefits package.
  • A hybrid and remote-friendly culture.

About Zelis
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. We foster a hybrid and remote-friendly culture and all of our employee's work locations are based on the needs of the position and determined by the Leadership team.

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