ECR Dispute Reviewer

Position Overview

What you'll do:

• 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.

What you'll bring to Zelis:

• Bachelor's degree in Nursing, Medicine, or a related healthcare field, or equivalent experience required. A Master's degree or higher is preferred.

• 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.

Base Salary Range

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 TalentAcquisition@zelis.com.

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.