Clinical Reviewer - Remote Position

ECR Dispute Reviewer job at Zelis. 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.

Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are.

The ECR Dispute Reviewer is responsible for conducting comprehensive clinical reviews of medical records, claims, and other healthcare documentation to ensure compliance with clinical guidelines, regulatory requirements, and organizational policies. This individual will play a critical role in supporting the quality and integrity of our clinical review processes, providing expert guidance, and contributing to the continuous improvement of our healthcare services. The ideal candidate will have extensive clinical experience, strong analytical skills, and a deep understanding of healthcare regulations and standards.

Conduct detailed clinical reviews of medical records, claims, and other healthcare documentation to assess the appropriateness of care, medical necessity, and compliance with clinical guidelines.

Ensure that clinical reviews are conducted in accordance with relevant regulatory requirements, accreditation standards, and organizational policies.

Stay up‑to‑date with changes in healthcare regulations, guidelines, and industry standards, and incorporate them into the review process.

Assist in the development and implementation of policies and procedures to ensure compliance with regulatory requirements.

Participate in quality assurance activities, including audits, peer reviews, and performance evaluations, to ensure the accuracy and consistency of clinical reviews.

Identify opportunities for process improvements and contribute to the development and implementation of quality improvement initiatives.

Provide training and mentorship to junior clinical reviewers and other team members to enhance their clinical review skills and knowledge.

Collaborate with healthcare providers, case managers, and other stakeholders to obtain additional information and clarify clinical documentation as needed.

Prepare and present reports on clinical review outcomes, trends, and performance metrics to management and other stakeholders.

Contribute to the development of clinical review guidelines, protocols, and educational materials.

Bachelor's degree in Nursing, Medicine, or a related healthcare field, or equivalent experience required. Minimum of 8 + years of clinical experience in a healthcare setting, with a strong background in clinical review, utilization management, or quality assurance.

Extensive knowledge of clinical guidelines, medical necessity criteria, and healthcare regulations (e.g., CMS, NCQA, URAC).

Proficiency in using clinical review software, electronic health records (EHR), and Microsoft Office Suite.

Committed to continuous learning and professional development, with a passion for improving healthcare quality and outcomes.

Please note at this time we are unable to proceed with candidates who require visa sponsorship now or in the future.

We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In‑office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies.

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.

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 believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all.

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.