Nurse Audit Lead

Elevance Health • Atlanta, IN

11d • Remote

About The Position

Nurse Audit Lead Location: Virtual : This role enables associates to work virtually full-time, except for 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. 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. The Nurse Audit Lead is responsible for leading a team of clinicians 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: Develops, maintains and enhances the claims review process. Assists management with developing unit goals, policies and procedures. Investigates potential fraud and over-utilization by performing the most complex 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. Acts as principal liaison with Service Operations as well as other areas of the corporation relative to claims reviews and their status. Notifies areas of identified problems or providers, recommending modifications to medical policy, on line policy edits. Communicates and negotiates with providers selected for prepayment review. Assists investigators by providing medical review expertise to accomplish the detection of fraudulent activities. Trains and provides guidance to nurse auditors and manages workflow and priorities for the unit.

Requirements

• Requires AS in nursing and minimum of 5 years of clinical experience and minimum of 2 years of claims review 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

• BA/BS preferred.
• Knowledge of auditing, accounting and control principals and working knowledge of CPT/HCPCS and ICD 9 coding and medical policy guidelines strongly preferred.
• Prior health care fraud audit/investigation experience preferred.
• Certification as a Professional Coder preferred.

Responsibilities

• Develops, maintains and enhances the claims review process.
• Assists management with developing unit goals, policies and procedures.
• Investigates potential fraud and over-utilization by performing the most complex 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.
• Acts as principal liaison with Service Operations as well as other areas of the corporation relative to claims reviews and their status.
• Notifies areas of identified problems or providers, recommending modifications to medical policy, on line policy edits.
• Communicates and negotiates with providers selected for prepayment review.
• Assists investigators by providing medical review expertise to accomplish the detection of fraudulent activities.
• Trains and provides guidance to nurse auditors and manages workflow and priorities for the unit.

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree