Elevance Health Nurse Audit Lead – Carelon Payment Integrity
Location: The ideal candidate will live within 50 miles of one of our pulse point locations and will work on a hybrid work model (1-2 days per week in the office).
Carelon Payment Integrity is a proud member of the Elevance Health family of companies, determined to recover, eliminate, and prevent unnecessary medical-expense spending.
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 healthcare 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, and 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.
- Travels to worksite and other locations as necessary.
Minimum 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.
Preferred Skills, Qualifications, and Experiences:
- BA/BS preferred.
- Experience in hospital bill auditing or defense auditing strongly preferred.
- Experience with provider manuals and reimbursement policies highly desired.
- Certification as a Professional Coder highly preferred.
- Knowledge of auditing, accounting, and control principals and working knowledge of CPT/HCPCS and ICD 10 coding and medical policy guidelines strongly preferred.
- Prior health care fraud audit/investigation experience preferred.
For candidates working in person or remotely in the below location(s), the salary range for this specific position is $83,412 to $142,992.
Locations: California; Colorado; District of Columbia (Washington, DC); Maryland; Nevada; New York; Washington State.
In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits are subject to eligibility requirements).
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
Elevance Health operates in a Hybrid Workforce Strategy. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to any protected status.
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