Zelis · 1 month ago
ECR Dispute Reviewer
US GA Atlanta
Full-time
Hybrid
Senior Level, Lead/Staff
$95K/yr - $127K/yr
8+ years expZelis is modernizing the healthcare financial experience across payers, providers, and healthcare consumers. The ECR Dispute Reviewer is responsible for conducting comprehensive clinical reviews of medical records and claims to ensure compliance with clinical guidelines and regulatory requirements, while also contributing to the continuous improvement of healthcare services.
FinanceFinTechHealth Care
No H1B
Responsibilities
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
Evaluate the accuracy and completeness of clinical documentation, identifying any discrepancies or areas for improvement
Provide expert clinical judgment and recommendations based on evidence-based guidelines and best practices
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
Communicate review findings and recommendations to internal and external stakeholders in a clear and concise manner
Participate in interdisciplinary team meetings, case conferences, and other collaborative activities to support coordinated care and decision-making
Maintain accurate and thorough documentation of clinical review activities, findings, and recommendations in the appropriate systems
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
Qualification
Required
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)
Experience in conducting clinical reviews and audits, with a proven track record of accuracy and attention to detail
Strong analytical and critical-thinking skills, with the ability to interpret complex clinical information and make sound clinical judgments
Excellent verbal and written communication skills, with the ability to convey clinical findings and recommendations clearly and professionally
Proficiency in using clinical review software, electronic health records (EHR), and Microsoft Office Suite
Ability to work independently and collaboratively in a fast-paced, dynamic environment
Detail-oriented and highly organized, with the ability to manage multiple tasks and priorities simultaneously
Proactive and self-motivated, with a strong sense of ownership and accountability
Committed to continuous learning and professional development, with a passion for improving healthcare quality and outcomes
Preferred
A Master's degree or higher is preferred
Current and unrestricted clinical licensure (e.g., RN, MD, DO) is preferred
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
Company
Zelis
Zelis is modernizing the healthcare financial experience for all.
1001-5000 employees
Funding
Current Stage
Late StageTotal Funding
$20.15MKey Investors
Mubadala
2024-12-04Private Equity
2020-01-05Private Equity· $20.15M
2019-01-01Private Equity
Leadership Team
Amanda Eisel
Chief Executive Officer
Brian Gladden
Chief Financial Officer
Recent News
2026-01-15
2025-12-10
Company data provided by crunchbase