Nurse Audit Lead

Supports the Carelon Payment Integrity line of business

Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles from our Elevance Health Pulse Point locations.

Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is 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 health care 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, on line policy edits.
• Trains and provides guidance to nurse auditors and manages workflow and priorities for the unit.
  
  

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.
• Current unrestricted RN license in applicable state(s) required.
• Travels to worksite and other locations as necessary.
  
  

Preferred Qualifications, Skills & Capabilities

• BA/BS preferred.
• Knowledge of auditing, accounting and control principals and working knowledge of CPT/HCPCS and ICD 10 coding and medical policy guidelines strongly preferred.
• Certification as a Professional Coder preferred.
• Hospital Bill Audit Experience preferred.
• Itemized Bill Review Experience preferred.
• Hospital Bill Audit/Itemized Bill Review Appeal Experience preferred.
  
  

For candidates working in person or remotely in the below locations, the salary* range for this specific position is $79,440 to $142,992.

Locations: California; Colorado; Hawaii; Nevada; New York; Washington State; Jersey City, NJ

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). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company.The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws .

• The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

Salary : $79,440 - $142,992