Nurse Auditor Senior - Carelon Payment Integrity

About the position

The Nurse Auditor Senior at Elevance Health is responsible for identifying, monitoring, and analyzing aberrant patterns of utilization and fraudulent activities by healthcare providers. This role involves conducting prepayment claims reviews, post-payment auditing, and provider record reviews to ensure compliance and integrity in medical billing practices. The position requires collaboration with various departments to improve processes and compliance, as well as providing medical review expertise to assist in fraud detection.

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 such as provider education, recovery of monies, and recommending sanctions.
• Assists with the development of audit tools, policies and procedures, and educational materials.
• Acts as a liaison with service operations and other areas of the company regarding claims reviews and their status.
• Analyzes and trends performance data, working with service operations to improve processes and compliance.
• Notifies areas of identified problems or providers, recommending modifications to medical policy and policy edits.
• Communicates and negotiates with providers selected for prepayment review.
• Assists investigators by providing medical review expertise to detect fraudulent activities.
• Serves as a resource to nurse auditors.
• Travels to worksite and other locations as necessary.

Requirements

• Requires AS in nursing and a minimum of 4 years of clinical nursing experience, or equivalent education and experience.
• Current unrestricted RN license in applicable state(s) required.

Nice-to-haves

• BA/BS preferred.
• Experience in hospital bill auditing or defense auditing strongly preferred.
• Experience with provider manuals and reimbursement policies highly desired.
• Certification as a Professional Coder highly preferred.
• Knowledge of auditing, accounting, and control principles, and working knowledge of CPT/HCPCS and ICD 10 coding and medical policy guidelines strongly preferred.
• Prior health care fraud audit/investigation experience preferred.

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution
• Paid Time Off
• Medical, dental, and vision insurance
• Short and long term disability benefits
• Life insurance
• Wellness programs
• Financial education resources