AddressDescription
Nurse Audit Senior
Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.
The Nurse Audit Senior will be responsible for identifying, monitoring, and analyzing aberrant patterns of ICD-10 coding and DRG assignment by health care providers through prepayment claims review, post payment auditing, and provider record review.
How you will make an impact:
- Performing medical reviews via prepayment claims review and post payment auditing to ensure billed diagnosis and procedure codes are supported in the medical record and assigned correctly per coding guidelines.
- Correlates review findings with appropriate actions (provider education, recovery of monies, cost avoidance, recommending sanctions or other actions).
- 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 edits.
- 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.
- Travels to worksite and other locations as necessary.
- BA/BS preferred.
- Medical claims review with prior health care fraud audit/investigation experience preferred. CCS, CIC, CCDS, RHIA, or RHIT preferred.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
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.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer and 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. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.comfor assistance.
