Nurse Auditor Senior - Integrity Complex and Clinical Audit

Anticipated End Date:

Position Title:

Nurse Auditor Senior – Payment Integrity Complex and Clinical Audit

Location:

This role is fully virtual with required in-person training sessions. Applicants must reside within a reasonable commuting distance if hybrid onsite is requested. Candidates outside commuting distance are not considered unless accommodation is granted by law.

• Investigate potential fraud and over-utilization through prepayment claims review and post payment auditing.
• Correlate review findings with appropriate actions: provider education, cost avoidance, sanctions or other actions.
• Assist with development of audit tools, policies, procedures and educational materials.
• Act as liaison with service operations and other areas regarding claims reviews and status.
• Analyze and trend performance data, collaborating with operations to improve processes and compliance.
• Notify areas of identified problems or providers, recommending modifications to medical policy and online policy edits.

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

• Knowledge of auditing, accounting and control principles and CPT/HCPCS, 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.

Job Level: Non-Management Exempt

Workshift: 1st Shift (United States of America)

Elevance Health is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws.