Nurse Audit Senior
Company: Elevance Health
Posted on: March 13, 2023
The Nurse Audit Senior position 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
- 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 online policy
- Communicates and negotiates with providers selected for
- Assists investigators by providing medical review expertise to
accomplish the detection of fraudulent activities.
- Serves as resource to nurse auditors. Minimum 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. Preferred Skills, Capabilities, and Experiences:
- Knowledge of auditing, accounting and control principles and a
working knowledge of CPT/HCPCS and ICD-10 coding, and medical
policy guidelines strongly preferred.
- Some local or overnight travel may be required.
- BA/BS preferred.
- Medical claims review with prior health care fraud
audit/investigation experience preferred.
- Certification as a Professional Coder preferred.
- Clinical DRG validation experience preferred. For candidates
working in person or remotely in the below locations, the salary*
range for this specific position is $63,072 to $126,144 Locations:
California; Colorado; Nevada; Washington State; Jersey City, NJ;
New York City, NY; Ithaca, NY and Westchester County, NY In
addition to your salary, Elevance Health offers benefits such as, a
comprehensive benefits package, incentive and recognition programs,
equity stock purchase and 401k contribution (all benefits are
subject to eligibility requirements). The salary offered for this
specific position is based on a number of legitimate,
non-discriminatory factors set by the company. The company is fully
committed to ensuring equal pay opportunities for equal work
regardless of gender, race, or any other category protected by
federal, state, and local pay equity laws . * The salary range is
the range Elevance Health in good faith believes is the range of
possible compensation for this role at the time of this posting.
This range may be modified in the future and actual compensation
may vary from posting based on geographic location, work
experience, education and/or skill level. Even within the range,
the actual compensation will vary depending on the above factors as
well as market/business considerations. No amount is considered to
be wages or compensation until such amount is earned, vested, and
determinable under the terms and conditions of the applicable
policies and plans. The amount and availability of any bonus,
commission, benefits, or any other form of compensation and
benefits that are allocable to a particular employee remains in the
Company's sole discretion unless and until paid and may be modified
at the Company's sole discretion, consistent with the law.
Keywords: Elevance Health, Concord , Nurse Audit Senior, Accounting, Auditing , Concord, California
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