Clinical Nurse Reviewer

Nurse Reviewer

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'll Do:

• 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.
• Attends company training and regularly attends local meetings (once per month).

What You'll Bring to Zelis:

• Current/active RN License.
• Typically has a BA or 3-5 years of experience.
• 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.

Base Salary Range

$59,000.00 - $75,050.00

At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role.

Zelis' full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees' health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage.

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. We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all.

Accessibility Support We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email View email address on click.appcast.io.

Disclaimer

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.