Nurse Audit

The Elevance Health Companies, Inc.; Deerfield Township (OH); Hybrid; USD 65,000 - 95,000; Full time

Benefits offered by this job

Hybrid/Virtual role

Onsite training sessions

Job summary

Elevance Health seeks a Nurse Audit professional to identify, monitor, and analyze aberrant utilization and potential fraud through prepayment and postpayment reviews. The role blends remote work with required in-person onboarding to ensure skill development.

Minimum requirements include an AS in nursing and an active RN license; 2+ years of clinical nursing experience is expected. Hybrid work arrangements may apply depending on location and policy.

Qualifications

• Requires AS in nursing and minimum of 2 years of clinical nursing experience.
• Current unrestricted RN license in applicable state(s) required.
• Certification in coding or related credentials preferred.

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, sanctions or other actions).
• Acts as liaison with service operations and other areas of the company related to claims reviews and their status.

Skills

Nursing

Auditing

CPT/HCPCS

ICD-9 coding

Fraud detection

Education

AS in nursing

RN license

Job description

Anticipated End Date: 2026-10-28 Position Title: Nurse Audit Job Description: Nurse Audit Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy.

This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Nurse Audit is responsible for identifying, monitoring and analyzing aberrant patterns of utilization and/or fraudulent activities by health care providers through prepayment claims review and post payment auditing.

How you will make an impact:

• 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).
• Acts as liaison with service operations as well as other areas of the company relative to claims reviews and their status.
• Notifies areas of identified problems or providers, recommending modifications to medical policy and online policy edits.

Minimum Requirements:

• Requires AS in nursing and minimum of 2 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.

Preferred Skills, Capabilities and Experiences:

• BA/BS preferred.
• Certification as a Professional Coder preferred.
• Knowledge of auditing, accounting and control principles and a working knowledge of CPT/HCPCS and ICD 9 coding and medical policy guidelines strongly preferred.
• Medical claims review with prior health care fraud audit/investigation experience preferred.

Job Level: Non-Management Exempt Workshift: Job Family: MED > Licensed Nurse

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health.

Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

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.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates.

Our values and behaviors are the root of our culture.

They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include

• merit increases
• paid holidays
• Paid Time Off
• incentive bonus programs (unless covered by a collective bargaining agreement)
• medical
• dental
• vision
• short and long term disability benefits
• 401(k) +match
• stock purchase plan
• life insurance
• wellness programs
• financial education resources

to name a few.

Elevance Health operates in a Hybrid Workforce Strategy.

Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week.

Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

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 and Influenza.

If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation.

Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.

Applicants who require accommodation to participate in the job application process should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM.

In other words - the job is posted until 3/13, not through 3/13.

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler.

Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

Join our Talent Community and stay connected with company news, information, and future job opportunities.

Fueled by our bold purpose to improve the health of humanity, we are transforming from a traditional health benefits organization into a lifetime trusted health partner. Our nearly 100,000 associates serve approximately 100M+ people, at every stage of health.

We address a full range of needs with an integrated whole health approach, powered by industry-leading capabilities and a digital platform for health.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.

Applicants who require accommodation to participate in the job application process should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration

Please visit the Contract Worker Community Page.

Elevance Health is an Equal Opportunity Employer/Disability/Veterans.