Nurse Audit Sr
| Company | Elevance Health |
|---|---|
| Location | Indianapolis, IN, USA, Wallingford, CT, USA, Atlanta, GA, USA |
| Salary | $Not Provided – $Not Provided |
| Type | Full-Time |
| Degrees | Associate’s |
| Experience Level | Senior |
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.
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.
Preferred Qualifications
- 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.
- Certification as a Professional Coder preferred.
- Knowledge of Hospital Bill Audit with utilizing UB/IB’s, bundling and Provider Manual language preferred.
- 4 years bedside nursing including either NICU or OR with specialty (Orthopedics, Cardiac etc)