Clinical Nurse Reviewer
About The Position
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. Zelis is modernizing the healthcare financial experience 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. At Zelis, AI is woven into the fabric of how we work. Every associate is expected - and empowered - to partner with AI to challenge the status quo, accelerate innovation, and amplify their impact. This is a place for builders with a growth mindset who act with agility, embrace change, and use modern technology to shape smarter solutions, exceptional experiences, and the future of our industry for our clients, customers, and our culture.
Requirements
- Typically has a BA or 3-5 years of experience
- Attends company training and local meetings in field
- Requires proficiency using AI tools skillfully with an understanding of how to develop/create intelligent prompts and/or agents.
- Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs preferred
- Familiarity with EHR systems and Microsoft Office.
- Exceptional attention to detail and ability to follow established processes.
- Committed to continuous learning and professional development, with a passion for improving healthcare quality and outcomes.
- Proactive and self-motivated, with a strong sense of ownership and accountability.
- Ability to withstand long period of computer work while utilizing multiple computer screens at one time
Responsibilities
- Conduct routine reviews of medical records and supporting documentation for compliance with clinical guidelines and organizational standards.
- Validate accuracy and completeness of documentation for basic cases, ensuring essential data elements are present.
- Identify and flag missing or incomplete information; escalate unresolved issues to senior reviewers.
- Contact medical providers via phone or email and request a review of billing inconsistencies
- Communicate findings clearly to internal teams, providing concise feedback on documentation gaps.
- Maintain current knowledge of healthcare regulations, payer requirements, and organizational policies.
- Support administrative tasks such as data entry, case tracking, and report preparation.
- Participate in training sessions and shadow senior reviewers to develop clinical review skills.
- Maintain personal production metrics and quality assurance scores consistently
- Maintain awareness of and ensure adherence to Zelis standards regarding privacy
Benefits
- 401k plan with employer match
- flexible paid time off
- holidays
- parental leaves
- life and disability insurance
- health benefits including medical, dental, vision, and prescription drug coverage
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
