Nurse Audit Lead
2 months ago
Elevance Health Nurse Audit Lead - Manchester, New Hampshire
Supports the Carelon Payment Integrity line of business
Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles from our Elevance Health Pulse Point locations.
Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending.
The
Nurse Audit Lead
is responsible for leading a team of clinicians responsible for identifying, monitoring, and analyzing aberrant patterns of utilization and/or fraudulent activities by health care providers through prepayment claims review, post payment auditing, and provider record review.
Responsibilities:
Develops, maintains, and enhances the claims review process.
Assists management with developing unit goals, policies, and procedures.
Investigates potential fraud and over-utilization by performing the most complex medical reviews via prepayment claims review and post payment auditing.
Correlates review findings with appropriate actions (provider education, recovery of monies, cost avoidance, recommending sanctions or other actions).
Acts as the principal liaison with Service Operations as well as other areas of the corporation relative to claims reviews and their status.
Notifies areas of identified problems or providers, recommending modifications to medical policy, on line policy edits.
Trains and provides guidance to nurse auditors and manages workflow and priorities for the unit.
Minimum Requirements:
AS in nursing and minimum of 5 years of clinical experience and minimum of 2 years of claims review experience; or any combination of education and experience, which would provide an equivalent background.
Preferred Qualifications, Skills & Capabilities:
BA/BS preferred.
Knowledge of auditing, accounting, and control principals and working knowledge of CPT/HCPCS and ICD 10 coding and medical policy guidelines strongly preferred.
Certification as a Professional Coder preferred.
Hospital Bill Audit Experience preferred.
Itemized Bill Review Experience preferred.
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