Nurse Reviewer

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

Key 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.

JOB REQUIREMENTS:

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 clinical resources like EncoderPro, Micromedex, Clinical Pharmacology, Milliman Care Guidelines/Interqual.
• Ability to navigate several webpages at one time and utilize other audit software and tools like MS Office Suite.
• Thorough knowledge of company and departmental policies and procedures.

Independence/ Accountability:

• Maintain personal production and savings quota
• Requires minimal daily supervision
• Regularly reviews goals and objectives with supervisor
• Achieve personal production goals and savings quotas
• Ability to follow detailed instructions on new assignments
• Accountable to 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

Problem Solving:

• 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.

Professional Experience:

• RN required
• Payment and/or Revenue Integrity 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.
• 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.
• Working knowledge of Health Insurance, Medicare guidelines and various healthcare programs.
• Clinical skills to evaluate appropriate Medical Record Coding.

Leadership Activities:

• 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.

Communication Skills:

• 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.