Zelis Healthcare - St. Louis, MO
posted 3 months ago
Full-time
Remote - St. Louis, MO
Professional, Scientific, and Technical Services
About the position
The Nurse Reviewer is responsible for conducting in-depth claim reviews based on medical guidelines, billing and coding rules, and payment errors. This role involves reviewing facility and outpatient bills against medical records and coverage policies to support internal inventory management and achieve savings for clients.
Responsibilities
- Conduct post-service, pre or post payment in-depth claim reviews based on accepted medical guidelines and clinical criteria.
- Review facility and outpatient bills in comparison with medical records and coverage policies.
- Support internal inventory management to achieve savings for clients.
- Maintain personal production and savings quota with minimal supervision.
- Oversee assigned projects/claims and manage escalations 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.
- 2+ years of auditing or performing claims review in specialty pharmacy claims or specialty drugs.
- Strong understanding and experience with Medicare and commercial drug reimbursement policies.
- Excellent written and verbal communication skills.
Nice-to-haves
- Experience with working with clients and/or payors directly preferred.
- Varied clinical experience, including Med/Surg, ICU or Emergency Medicine preferred.
- Payment Integrity, Coding and/or DRG experience preferred.
Benefits
- Hybrid and remote friendly work culture.
- Diversity, equity, inclusion, and belonging initiatives.
- Equal Employment Opportunity policies.
