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Clinical Audit Supervisor
2 months ago
The Clinical Audit Supervisor plays a pivotal role in the Carelon Payment Integrity division of Elevance Health. This position is designed for individuals who are committed to enhancing the integrity of healthcare claims and ensuring compliance with medical policies.
Key Responsibilities:
- Lead a dedicated team of healthcare professionals focused on identifying and analyzing unusual patterns in healthcare utilization and potential fraudulent activities.
- Oversee the claims review process, ensuring it is effective and efficient.
- Collaborate with management to establish unit objectives, policies, and procedures.
- Conduct in-depth investigations into suspected fraud and over-utilization through comprehensive medical reviews.
- Align review outcomes with appropriate actions, including provider education, financial recovery, and policy modifications.
- Serve as the primary contact for Service Operations and other departments regarding claims review statuses.
- Provide training and support to nurse auditors, managing their workflow and priorities.
Qualifications:
- An Associate's degree in nursing is required, along with a minimum of five years of clinical experience and at least two years in claims review.
- A Bachelor's degree is preferred.
- Familiarity with auditing principles, CPT/HCPCS, and ICD-10 coding is highly desirable.
- Certification as a Professional Coder is a plus.
- Experience in hospital bill audits and itemized bill reviews is preferred.
Work Environment:
This role supports a hybrid work model, allowing for both remote and in-office work. Candidates should ideally reside within a reasonable distance from Elevance Health's operational locations.
Compensation and Benefits:
The salary range for this position is competitive and based on various factors, including experience and location. Elevance Health offers a comprehensive benefits package, including health insurance, retirement plans, and equity stock purchase options. The company is committed to equitable pay practices and values diversity in the workplace.
