Nurse Audit Senior

Elevance Health•Atlanta, GA

1d•Hybrid

About The Position

The Nurse Audit Senior conducts on-site reviews of medical charts, medical notes, itemized bills and providers contracts to ensure that a claim is paid in accordance with the contract, provider reimbursement policies, and industry standards. The Nurse Audit Senior 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.

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.
Travels to worksite and other locations as necessary.
BA/BS preferred.
Medical claims review with prior health care fraud audit/investigation experience preferred.
Certification as a Professional Coder preferred.

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.
Communicates and negotiates with providers selected for prepayment review.
Assists investigators by providing medical review expertise to accomplish the detection of fraudulent activities.
Serves as resource to nurse auditors.