Senior Nurse Auditor – Payment Integrity, Complex and Clinical Audit
Elevance Health
full-time
Posted on:
Location Type: Hybrid
Location: Mason • Kentucky, Ohio, Tennessee • 🇺🇸 United States
Visit company websiteJob Level
Senior
About the role
- Investigates potential fraud and over-utilization by performing medical reviews via prepayment claims review and post payment auditing
- Correlates review findings with appropriate actions (provider education, recovery of monies, cost avoidance, recommending sanctions or other actions)
- Assists with development of audit tools, policies and procedures and educational materials
- Acts as liaison with service operations as well as other areas of the company relative to claims reviews and their status
- Analyzes and trends performance data, and works with service operations to improve processes and compliance
- Notifies areas of identified problems or providers, recommending modifications to medical policy and online policy edits
Requirements
- Requires AS in nursing and minimum of 4 years of clinical nursing experience; or any combination of education and experience, which would provide an equivalent background.
- Current unrestricted RN license in applicable state(s) required.
- Knowledge of auditing, accounting and control principles and a working knowledge of CPT/HCPCS and ICD 9 coding and medical policy guidelines strongly preferred
- BA/BS preferred
- Medical claims review with prior health care fraud audit/investigation experience preferred
- Knowledge of Provider Manuals and Reimbursement policies is preferred
Benefits
- merit increases
- paid holidays
- Paid Time Off
- incentive bonus programs
- medical
- dental
- vision
- short and long term disability benefits
- 401(k) +match
- stock purchase plan
- life insurance
- wellness programs
- financial education resources
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
medical reviewsprepayment claims reviewpost payment auditingaudit tools developmentperformance data analysisCPT codingHCPCS codingICD 9 codingmedical policy guidelinesprovider education
Soft skills
analytical skillscommunicationliaisonproblem-solvingorganizational skills
Certifications
RN licenseAS in nursingBA/BS