Nurse Audit Senior – Payment Integrity Complex and Clinical Audit at Elevance Health

Mason, Ohio, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

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)

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 online policy edits
Identifies, monitors, and analyzes aberrant patterns of utilization and/or fraudulent activities by health care providers through prepayment claims review, post payment auditing, and provider record review

Skills

medical review

prepayment claims review

post payment auditing

provider record review

fraud investigation

utilization review

audit tools development

claims analysis

performance trending

compliance

provider education

Elevance Health

Integrated health services and digital platform

About Elevance Health

Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.

Indianapolis, IndianaHeadquarters

1944Year Founded

$309.4MTotal Funding

IPOCompany Stage

Enterprise Software, Social Impact, HealthcareIndustries

10,001+Employees

Benefits

Medical, dental, & vision insurance

401(k) + match

Paid holidays

Paid Time Off

Incentive bonus programs

Stock purchase plan

Life insurance

Wellness Programs

Financial education resources

Adoption & Surrogacy Assistance

Dependent-care Flexible Spending Account (DCFSA)

Parental Leave

Parental Transition Week

Critical Caregiving Leave

Risks

Departure of CFO John Gallina may create a gap in financial leadership.

Lawsuit against CMS over MA Star Ratings could lead to financial penalties.

CareBridge integration may face operational challenges, disrupting service delivery.

Differentiation

Elevance Health integrates whole health approach with digital health platform for comprehensive care.

Acquisition of CareBridge enhances home health services within Carelon division.

Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.

Upsides

AI integration in home health services can reduce hospital readmissions and improve outcomes.

Predictive analytics support early disease detection, aligning with Elevance's whole health approach.

Telehealth expansion offers opportunities to reach more patients remotely.

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