RN Hospital Bill Audit/Appeal Lead

14 hours ago


Woburn, Massachusetts, United States Elevance Health Full time
RN Hospital Bill Audit/Appeal Lead Job Summary

We are seeking a highly skilled and experienced 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, monitoring, 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, online policy edits, and training for nurse auditors.
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.
  • Ability to 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:

Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution. The salary range for this position is $83,412 to $142,992, based on a number of legitimate, non-discriminatory factors set by the company.

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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