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Remote - Nurse Reviewer (Hospital Bill Review) Job in Bedminster, New Jersey

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Job Title: Remote - Nurse Reviewer (Hospital Bill Review)

Employer:Zelis Healthcare
Job Location:Remote
Skills:Must be RN or LPN,Impatient Facility Claims,Itemized Bill Review,Claims Auditing,Coding knowledge - CPT,ICD-10,HCPC
Preferred Certifications:CIC,CPC,CCS
Required Experience:3 to 4 years
Preferred Experience:3 to 4 years
Location:2 Crossroads Drive Bedminster 07921, NJ, US
* Note: This listing is for a remote position
Date Posted:6/3/2021
Position Overview:

The Nurse Reviewer will be primarily responsible for conducting post-service, pre-payment in-depth claim reviews based on accepted medical necessity guidelines, billing and coding rules, plan policy exclusions, and clinical or 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:

  • Review itemized bill for medical appropriateness and billing inconsistencies by performing a line by line clinical review of a 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 claims 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 recommended 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 claims 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 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
  • Achieve personal production goals and savings quotas
  • 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
Professional Experience:

  • LPN or RN required
  • Coding and DRG 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
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.

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.

“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.”



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