Nurse Audit Senior - Operating Room

Elevance Health • Atlanta, IN

8d • Remote

About The Position

Nurse Audit Senior- Operating Room Location: Virtual : This role enables associates to work virtually full-time, except for 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 Nurse Audit Senior- Operating Room is responsible for for identifying, monitoring, and analyzing aberrant patterns of utilization and/or fraudulent activities by health care providers through prepayment claims review, post payment auditing, and provider record review. How you will make an impact: 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 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. Serves as resource to nurse auditors.

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.

Nice To Haves

• Knowledge of auditing, accounting and control principles and a working knowledge of CPT/HCPCS and ICD 10 coding and medical policy guidelines strongly preferred.
• BA/BS preferred.
• Medical claims review with prior health care fraud audit/investigation experience preferred.
• Professional Coder Certification 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).
• 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 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.
• Serves as resource to nurse auditors.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree