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RN Hospital Bill Audit/Appeal Lead

2 months ago

Woburn, Massachusetts, United States Elevance Health Full time
About the Role

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 Carelon 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
  • Assist management in developing unit goals, policies, and procedures
  • Investigate potential fraud and over-utilization through 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
  • Train and provide guidance to nurse auditors and manage workflow and priorities for the unit
Requirements
  • AS in nursing and minimum of 5 years of clinical experience and minimum of 2 years of claims review experience
  • Current unrestricted RN license in applicable state(s) required
  • 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
What We Offer

We offer a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution. Our salary range for this position is $79,440 to $142,992, depending on location and experience.

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.