Nurse Audit Senior

Elevance Health • Atlanta, GA

5d • Hybrid

About The Position

Nurse Audit Senior - Licensed Nurse Location: Atlanta, GA; Norfolk, VA & Indianapolis, IN Hybrid 1: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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 c onducts on-site reviews of medical charts, medical notes, itemized bills and providers contracts to ensure that a claim is paid in accordance with the contract, provider reimbursement policies, and industry standards. The Nurse Audit Senior is responsible 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 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).
• 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
• Number of Employees: 5,001-10,000 employees