Nurse Clinical Reviewer

ECR - Nurse / Clinical Reviewer

About Us 

Zelis is modernizing the healthcare financial experience in the United States (U.S.) across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. 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.

What you will do:

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• 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

 

 

What you will bring: Required

• 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. 

• Shift time - 02:00 PM - 11:00 PM IST . Work from Office , No Hybrid.

Other:

• Embody Culture and Values

Benefits/Perks:

The well-being of Zelis associates is essential:

• Industry leading Healthcare

  • Caregiving benefits

  • Family Forming & Reproductive Health Benefits

  • And more!

• Access to Mental Well-being Resources

• Savings & Investments (401K)

• Paid Holidays and PTO

• Educational Resources

• Giving programs

• Opportunities to network and connect

• Discounts on products and services

 

Disclaimer:

We are an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, national origin, disability status, protected veteran status, or any other characteristic protected by law.

 

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.

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 qualified 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.

Accessibility Support

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