Audit Nurse (US)
About The Position
Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Audit Nurse is responsible for identifying, monitoring and analyzing aberrant patterns of utilization and/or fraudulent activities by health care providers through prepayment claims review and post payment auditing. Must have Ohio license or compact license How you'll make a difference: 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). Acts as liaison with service operations as well as other areas of the company relative to claims reviews and their status. Notifies areas of identified problems or providers, recommending modifications to medical policy and on line policy edits. Communicates and negotiates with providers selected for prepayment review. Assists investigators by providing medical review expertise to accomplish the detection of fraudulent activities.
Requirements
- Requires AS in nursing and minimum of 2 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.
Nice To Haves
- Knowledge of auditing, accounting and control principles and a working knowledge of CPT/HCPCS and ICD 9 coding and medical policy guidelines strongly preferred.
- Travels to worksite and other locations as necessary.
- BA/BS preferred.
- Medical claims review with prior health care fraud audit/investigation experience preferred.
- Certification as a Professional Coder preferred.
Responsibilities
- 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).
- Acts as liaison with service operations as well as other areas of the company relative to claims reviews and their status.
- Notifies areas of identified problems or providers, recommending modifications to medical policy and on line policy edits.
- Communicates and negotiates with providers selected for prepayment review.
- Assists investigators by providing medical review expertise to accomplish the detection of fraudulent activities.
Benefits
- a comprehensive benefits package
- incentive and recognition programs
- equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements)
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
