ECR Dispute Reviewer

About the position At Zelis, we Get Stuff Done. So, let’s get to it! A Little About Us 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. A Little About You You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are. Position Overview 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.

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.

Requirements

• Bachelor's degree in Nursing, Medicine, or a related healthcare field, or equivalent experience required.
• Current and unrestricted clinical licensure (e.g., RN, MD, DO) is preferred.
• 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.

Nice-to-haves

• A Master's degree or higher is preferred.

Benefits

• 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.

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