Nurse Audit
Elevance Health•Tampa, FL
•Remote
About The Position
The Nurse Audit is responsible for identifying, monitoring and analyzing aberrant patterns of utilization and/or fraudulent activities by health care providers through prepayment claims review and post payment auditing.
Requirements
- Requires AS in nursing and minimum of 2 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
- BA/BS preferred.
- Certification as a Professional Coder preferred.
- Knowledge of auditing, accounting and control principles and a working knowledge of CPT/HCPCS and ICD 9 coding and medical policy guidelines strongly preferred.
- Medical claims review with prior health care fraud audit/investigation experience 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).
- Acts as liaison with service operations as well as other areas of the company relative to claims reviews and their status.
- Notifies areas of identified problems or providers, recommending modifications to medical policy and online policy edits.
Benefits
- merit increases
- paid holidays
- Paid Time Off
- incentive bonus programs
- medical
- dental
- vision
- short and long term disability benefits
- 401(k) +match
- stock purchase plan
- life insurance
- wellness programs
- financial education resources
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
