RN Hospital Bill Audit/Appeal Lead

5 days ago


Atlanta, Georgia, United States Elevance Health Full time
Job Summary

We are seeking a highly skilled RN Hospital Bill Audit/Appeal Lead to join our team at Elevance Health. As a key member of our Payment Integrity line of business, you will be responsible for leading a team of clinicians in identifying and analyzing aberrant patterns of utilization and/or fraudulent activities by healthcare providers.

Key Responsibilities
  • Develop, maintain, and enhance the claims review process to ensure accuracy and efficiency.
  • Assist management in developing unit goals, policies, and procedures to drive business outcomes.
  • Investigate potential fraud and over-utilization by performing complex 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 or other actions.
  • Act as a principal liaison with Service Operations and other areas of the corporation relative to claims reviews and their status.
  • Notify areas of identified problems or providers, recommending modifications to medical policy and online policy edits.
  • Train and provide guidance to nurse auditors and manage workflow and priorities for the unit.
Requirements
  • Requires an Associate's degree in nursing and a minimum of 5 years of clinical experience and 2 years of claims review experience, or any combination of education and experience that provides an equivalent background.
  • Current unrestricted RN license in applicable state(s) required.
  • Travel to worksite and other locations as necessary.
Preferred Qualifications
  • BA/BS preferred.
  • Knowledge of auditing, accounting, and control principles 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.
  • Hospital Bill Audit/Itemized Bill Review Appeal Experience preferred.
What We Offer

We offer a range of market-competitive total rewards, including merit increases, paid holidays, Paid Time Off, and incentive bonus programs. Our comprehensive benefits package includes medical, dental, vision, short and long-term disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs, and financial education resources.

Elevance Health operates in a Hybrid Workforce Strategy. Associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. 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. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other status or condition protected by applicable federal, state, or local laws.



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