[Hiring] Nurse Audit Senior - Operating Room @Elevance Health
Role Description
The Nurse Audit Senior - Operating Room 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.
ā¢ Investigates potential fraud and over-utilization by performing medical reviews via prepayment claims review and post payment auditing.
ā¢ Correlates review findings with appropriate actions (provider education, recovery of monies, cost avoidance, recommending sanctions or other actions).
ā¢ Assists with development of audit tools, policies and procedures and educational materials.
ā¢ Acts as liaison with service operations as well as other areas of the company relative to claims reviews and their status.
ā¢ Analyzes and trends performance data, and works with service operations to improve processes and compliance.
ā¢ Notifies areas of identified problems or providers, recommending modifications to medical policy and online policy edits.
ā¢ Communicates and negotiates with providers selected for prepayment review.
ā¢ Assists investigators by providing medical review expertise to accomplish the detection of fraudulent activities.
ā¢ Serves as resource to nurse auditors.
Qualifications
ā¢ 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.
ā¢ Current unrestricted RN license in applicable state(s) required.
Requirements
ā¢ Knowledge of auditing, accounting and control principles and a working knowledge of CPT/HCPCS and ICD 10 coding and medical policy guidelines strongly preferred.
ā¢ BA/BS preferred.
ā¢ Medical claims review with prior health care fraud audit/investigation experience preferred.
ā¢ Professional Coder Certification preferred.
Benefits
ā¢ Merit increases.
ā¢ Paid holidays.
ā¢ Paid Time Off.
ā¢ Incentive bonus programs (unless covered by a collective bargaining agreement).
ā¢ Medical, dental, vision benefits.
ā¢ Short and long term disability benefits.
ā¢ 401(k) + match.
ā¢ Stock purchase plan.
ā¢ Life insurance.
ā¢ Wellness programs.
ā¢ Financial education resources.
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The Nurse Audit Senior - Operating Room 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.
ā¢ Investigates potential fraud and over-utilization by performing medical reviews via prepayment claims review and post payment auditing.
ā¢ Correlates review findings with appropriate actions (provider education, recovery of monies, cost avoidance, recommending sanctions or other actions).
ā¢ Assists with development of audit tools, policies and procedures and educational materials.
ā¢ Acts as liaison with service operations as well as other areas of the company relative to claims reviews and their status.
ā¢ Analyzes and trends performance data, and works with service operations to improve processes and compliance.
ā¢ Notifies areas of identified problems or providers, recommending modifications to medical policy and online policy edits.
ā¢ Communicates and negotiates with providers selected for prepayment review.
ā¢ Assists investigators by providing medical review expertise to accomplish the detection of fraudulent activities.
ā¢ Serves as resource to nurse auditors.
Qualifications
ā¢ 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.
ā¢ Current unrestricted RN license in applicable state(s) required.
Requirements
ā¢ Knowledge of auditing, accounting and control principles and a working knowledge of CPT/HCPCS and ICD 10 coding and medical policy guidelines strongly preferred.
ā¢ BA/BS preferred.
ā¢ Medical claims review with prior health care fraud audit/investigation experience preferred.
ā¢ Professional Coder Certification preferred.
Benefits
ā¢ Merit increases.
ā¢ Paid holidays.
ā¢ Paid Time Off.
ā¢ Incentive bonus programs (unless covered by a collective bargaining agreement).
ā¢ Medical, dental, vision benefits.
ā¢ Short and long term disability benefits.
ā¢ 401(k) + match.
ā¢ Stock purchase plan.
ā¢ Life insurance.
ā¢ Wellness programs.
ā¢ Financial education resources.
Apply Now
Apply Now