Zelis Hiring for Nurse Reviewer – Hospital Billing Job at Remote Full Time

Zelis is a healthcare and financial technology growth company and market-leading provider of claims cost management and payments optimization solutions to price, pay and explain healthcare claims. Zelis delivers integrated network analytics, network solutions, payment integrity, electronic payments and claims communications for payers, healthcare providers and consumers in the medical, dental and workers’ compensation markets nationwide. Zelis is backed by Parthenon Capital Partners and Bain Capital.

Zelis requires proof of Covid-19 vaccination upon hire.

POSITION OVERVIEW:

The Dispute Nurse Reviewer will be primarily responsible for reviewing and responding to provider appeals for facility inpatient and outpatient claims based on proper billing or coding guidelines, plan policy exclusions, and clinical or payment errors/overpayments. This role will be responsible for conducting appeal review of facility inpatient and outpatient claims as it compares with the itemized bill, medical records, and coverage policies. Occasionally, supporting the reviews on calls with clients or providers may be necessary.

KEY RESPONSIBILITIES:

• · Responsible for conducting detailed review facility claim appeals in response to billing, coding, medical necessity, experimental and investigational, plan policy exclusions or other clinical denials.
• · Submit Appeal Review response back to clients/ providers based on appeal findings within the designated timeframe to ensure client turnaround times are met
• · Document all aspects of appeal including uploading all provider communications, clinical and/or financial research
• · Participate in client meetings to explain and support HBR product reviews and results
• · Maintain professional/consistent communication with internal nurse review team and itemized bill review team and provide appeal feedback as requested by management
• · Must have an understanding of health plans and lines of business in addition to their interaction with policies and coding guidelines
• · Remain current in all national coding guidelines, including Official Coding Guidelines, AMA, CMS, and AHA Coding Clinic
• · Meet or exceed appeal accuracy and personal production standards
• · Prepare appeal report summaries based on appeal results as requested by management
• · Respond to inquiries from Client Services and Provider Support Services in a timely manner regarding appeal reviews when requested by manager
• Recommend new methods to improve departmental procedures
• Adhere to SOPs as it relates to all appeal types
• Maintain awareness of and ensure adherence to Zelis standards regarding privacy with each appeal reviewed

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 CMS, EncoderPro, other audit software and tools, MS Office Suite
• Thorough knowledge of company and departmental policies and procedures
• Independence/ Accountability:
• Requires minimal daily supervision
• Regularly reviews goals and objectives with supervisor
• Ability to follow detailed instructions on new assignments
• Accountable to day-to-day tasks
• Must have 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
• 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

Business-related Travel:

• Travel requirements to (primarily) domestic destinations should not exceed 10%

PROFESSIONAL EXPERIENCE:

• LPN or RN required; AHIMA or AAPC coding certification preferred
• 3-5 years of auditing, claims review, and/or billing experience with a health care organization required; prior appeal experience preferred
• Business writing and oral communications proficiency
• Demonstrates expert understanding of audit and/or appeal procedures
• Extensive knowledge of reimbursement methodologies and acceptable billing practices
• Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs
• Highly organized with attention to detail
• Strong analytical and critical thinking skills
• Excellent written and verbal communication skills

PHYSICAL DEMANDS:

• Walking, standing, and sitting.
• Long periods of computer usage.
• Handling – seizing, holding, grasping and fingering of objects, tools and controls.
• Reaching.
• Vision – close vision.
• Hearing- ability to receive detailed information through oral and telephonic communication.
• Ability to lift and move approximately thirty (30) pounds on a non-routine basis.
• Ability to sit for extended periods of 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.

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

Job Type: Full-time

Pay: Up to $110,000.00 per year

Benefits:

• 401(k) matching
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance
• Work from home

Schedule:

• Day shift

Experience:

• Inpatient Billing: 2 years (Preferred)

Work Location:

• Fully Remote

Work Location: Remote