Utilization review nurse Jobs in College Station, TX

Position Overview

At Zelis, the Itemized Bill Review Facility Reviewer is responsible for analyzing facility inpatient and outpatient claims for Health Plans and ensuring adherence to proper billing guidelines. They will work closely with Hospital Bill Review and Concept Development staff to efficiently identify and adhere to policies and procedures for claims processing. This position will also be responsible for developing new concepts, assisting with the quality assurance program, and being a resource for the entire organization regarding IBR claims. This is a production-based role with production metrics goals.

Key Responsibilities :

Conduct detailed review of hospital itemized bills for identification of billing and coding opportunities for all payor’s claims including restricted list

Review client payment policy documents : interpret and document the configurations to be applied to Zelis coding and clinical reviews

Translate client reimbursement policies into Zelis coding and clinical concepts

Provide direction to internal team based on understanding of client payment policies

Understand payor policies and their application to claims processing

Prepare and upload documentation clearly identifying findings

Accurately calculate / verify the value of review and documentation for claim processing

Monitor multiple reports to track client specific requirements, turnaround time and overall claims progression

Complete claims processing after the Clinical Bill Review and Audit analysis is completed.

Assist in appeals process as necessary

Collaborate between multiple areas within the department

Evaluate current Quality Assurance Process and implement recommended changes for efficiency & effectiveness

Monitor, research, and summarize changes as client reimbursement policy changes

Maintain individual productivity standard of 12 claims accepted per day with a savings acceptance threshold not to exceed TBC $1,000,000.00

Consistently meet or exceed personal quality standard of 85%

Lend expertise to implementation team as necessary

Act as a coding subject matter expert for department and clients

Remain current in all national coding guidelines including Official Coding Guidelines and AHA Coding Clinic and share with review team

Maintain awareness of and ensure adherence to Zelis standards regarding privacy

Qualifications :

CPC credential preferred

Working knowledge of health / medical insurance and handling of claims

General knowledge of provider claims / billing, with medical coding and billing experience

Knowledge of ICD-10 and CPT coding

Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers

Ability to manage and prioritize multiple tasks with strong attention to detail

Diligent research and organizational skills

Excellent verbal and written communication skills

Ability to work under pressure, meet deadlines, and prioritize tasks.

Proficient in Microsoft Office, more importantly Outlook, Excel, and Word

Excellent organizational and project management skills are required to prioritize responsibilities, thus completing work in a timely fashion.

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

Location and Workplace Flexibility : We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture and all of 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.