Nurse Audit Senior (Operating Room)

Elevance Health; Mason (OH); Remote; USD 82,000 - 124,000; Full time

Job summary

A leading health company is seeking a Nurse Audit Senior to identify and analyze fraudulent activities in healthcare claims. This position offers flexibility to work virtually full-time, with a minimum requirement of an AS in nursing and 4 years of clinical experience. The role includes investigating medical reviews and developing audit tools. The ideal candidate is autonomous, skilled in communication, and knowledgeable about auditing practices.

Benefits

Comprehensive benefits package

Incentive and recognition programs

401k contribution

Qualifications

• Minimum of 4 years of clinical nursing experience required.
• Current unrestricted RN license in applicable state(s) required.

Responsibilities

• Investigates potential fraud and over-utilization.
• Assists with development of audit tools and procedures.
• Communicates with providers for claims review.

Skills

Clinical nursing experience

Fraudulent activity detection

Communication with providers

Education

AS in nursing

Unrestricted RN license

Tools

CPT/HCPCS coding knowledge

Medical policy guidelines

Job description

Overview

Anticipated End Date: 2025-10-10

Position Title: Nurse Audit Senior (Operating Room)

Job Description:

Nurse Audit Senior (Operating Room)

Virtual: 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.

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 Senior is 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.

Location: Colorado

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.
• Communicates and negotiates with providers selected for prepayment review.
• Assists investigators by providing medical review expertise to accomplish the detection of fraudulent activities. Serves as resource to nurse auditors.

Minimum 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.

Preferred Skills, Capabilities and Experiences

• Operating room and/or auditing experience highly preferred.
• Medical claims review with prior health care fraud audit/investigation experience highly preferred.
• Knowledge of auditing, accounting and control principles and a working knowledge of CPT/HCPCS and ICD 10 coding and medical policy guidelines strongly preferred.
• Travels to worksite and other locations as necessary.
• BA/BS preferred.
• Certification as a Professional Coder preferred.

Salary and Location

For candidates working in person or virtually in the location below, the salary range for this specific position is $82,192 to $123,288.

Locations: Colorado

Benefits and Pay Equity

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.

Job Details

Job Level: Non-Management Exempt

Workshift:

Job Family: MED > Licensed Nurse

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, 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 may contact Elevance Health job support for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws.