Nurse Auditor Senior

2 weeks ago


Wilmington, Delaware, United States Elevance Health Full time
About the Role

We are seeking a highly skilled Nurse Auditor Senior to join our team at Elevance Health. As a key member of our Carelon Payment Integrity department, you will play a critical role in identifying and preventing unnecessary medical-expense spending.

Key Responsibilities
  • Investigate potential fraud and over-utilization by performing medical reviews via prepayment claims review and post-payment auditing.
  • Correlate review findings with appropriate actions, including provider education, recovery of monies, cost avoidance, and recommending sanctions.
  • Assist with the development of audit tools, policies, and procedures, as well as educational materials.
  • Act as a liaison with service operations and other areas of the company relative to claims reviews and their status.
  • Analyze and trend performance data, working with service operations to improve processes and compliance.
  • Notify areas of identified problems or providers, recommending modifications to medical policy and policy edits.
  • Communicate and negotiate with providers selected for prepayment review.
  • Assist investigators by providing medical review expertise to detect fraudulent activities.
  • Serve as a resource to nurse auditors.
Requirements
  • Requires an Associate's degree in nursing and a minimum of 4 years of clinical nursing experience, or any combination of education and experience that provides an equivalent background.
  • Current unrestricted RN license in applicable state(s) required.
Preferred Qualifications
  • BA/BS preferred.
  • Experience in hospital bill auditing or defense auditing strongly preferred.
  • Experience with provider manuals and reimbursement policies highly desired.
  • Certification as a Professional Coder highly preferred.
  • Knowledge of auditing, accounting, and control principles, as well as working knowledge of CPT/HCPCS and ICD 10 coding and medical policy guidelines strongly preferred.
  • Prior healthcare fraud audit/investigation experience preferred.
About Elevance Health

Elevance Health is a health company dedicated to improving lives and communities. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

We offer a range of market-competitive total rewards, including merit increases, paid holidays, Paid Time Off, and incentive bonus programs. In addition, we provide comprehensive benefits, equity stock purchase, and 401(k) contribution, among others.

Elevance Health operates in a Hybrid Workforce Strategy, with associates required to work at an Elevance Health location at least once per week. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19.


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