Job Description
About the position Nurse Auditor Senior – Payment Integrity Complex and Clinical Audit 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. 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. Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending. The Nurse Audit Senior will be 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. 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 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 • BA/BS preferred • Medical claims review with prior health care fraud audit/investigation experience preferred • Knowledge of Provider Manuals and Reimbursement policies is preferred 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. Apply tot his job