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RN Hospital Bill Audit/Appeal Lead
2 months ago
We are seeking a highly skilled and experienced RN Hospital Bill Audit/Appeal Lead to join our team at Elevance Health. As a Clinical Lead, you will be responsible for leading a team of clinicians in identifying, monitoring, and analyzing aberrant patterns of utilization and/or fraudulent activities by healthcare providers.
Key Responsibilities- Develop and Maintain Claims Review Process: Develop, maintain, and enhance the claims review process to ensure accuracy and efficiency.
- Collaborate with Management: Assist management in developing unit goals, policies, and procedures to drive business outcomes.
- Investigate Potential Fraud and Over-Utilization: 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: Correlate review findings with appropriate actions, including provider education, recovery of monies, cost avoidance, and recommending sanctions or other actions.
- Act as Liaison with Service Operations: Act as a principal liaison with Service Operations and other areas of the corporation relative to claims reviews and their status.
- Train and Guide Nurse Auditors: Train and provide guidance to nurse auditors and manage workflow and priorities for the unit.
- Education and Experience: Requires an Associate's degree in nursing and a minimum of 5 years of clinical experience and a minimum of 2 years of claims review experience, or any combination of education and experience that would provide an equivalent background.
- Current Unrestricted RN License: Current unrestricted RN license in applicable state(s) required.
- Travel Requirements: Travels to worksite and other locations as necessary.
- BA/BS Degree: BA/BS degree preferred.
- Knowledge of Auditing and Accounting Principles: 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: Certification as a Professional Coder preferred.
- Hospital Bill Audit Experience: Hospital Bill Audit experience preferred.
- Itemized Bill Review Experience: Itemized Bill Review experience preferred.
- Hospital Bill Audit/Itemized Bill Review Appeal Experience: Hospital Bill Audit/Itemized Bill Review Appeal experience preferred.
