RN Hospital Bill Audit/Appeal Lead
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About The Position
The RN Hospital Bill Audit/Appeal Lead plays a crucial role within the Carelon Payment Integrity line of business, which is part of the Elevance Health family of companies. This position is designed for a hybrid work model, allowing for both remote and office work, with a preference for candidates residing within 50 miles of Elevance Health Pulse Point locations. The primary responsibility of the RN Hospital Audit/Appeal Lead is to lead a team of clinicians in identifying, monitoring, and analyzing aberrant patterns of utilization and potential fraudulent activities by healthcare providers. This is achieved through comprehensive prepayment claims reviews, post-payment auditing, and thorough provider record reviews. In this role, the RN Hospital Audit/Appeal Lead will develop, maintain, and enhance the claims review process, ensuring that it meets the highest standards of accuracy and efficiency. The lead will assist management in formulating unit goals, policies, and procedures that align with the overall objectives of the organization. A significant aspect of the position involves investigating potential fraud and over-utilization by conducting complex medical reviews, which include both prepayment claims reviews and post-payment audits. The lead will correlate review findings with appropriate actions, which may include provider education, recovery of funds, cost avoidance strategies, and recommending sanctions or other necessary actions. Additionally, the RN Hospital Audit/Appeal Lead will act as the principal liaison with Service Operations and other corporate areas regarding claims reviews and their statuses. This includes notifying relevant parties of identified problems or providers and recommending modifications to medical policies and online policy edits. Training and providing guidance to nurse auditors is also a key responsibility, as is managing workflow and priorities within the unit. This position is integral to ensuring the integrity of the payment process and the overall financial health of the organization.
