Nurse Auditor Senior - Payment Integrity Complex and Clinical Audit

Elevance Health; Remote; USD 85,000 - 105,000; Full time

Job summary

A healthcare company is seeking a Nurse Auditor Senior to investigate potential fraud and manage clinical audits. This role requires a minimum of 4 years of clinical nursing experience and an unrestricted RN license. Responsibilities include developing audit tools, analyzing performance data, and collaborating with service operations to ensure compliance. The position is fully virtual with mandatory in-person training sessions, offering an opportunity for impactful work in a dynamic environment.

Qualifications

• Minimum 4 years of clinical nursing experience; or equivalent combination of education and experience.
• Current unrestricted RN license in applicable state(s) required.

Responsibilities

• Investigate potential fraud through claims review and auditing.
• Assist with development of audit tools and educational materials.
• Analyze performance data to improve processes and compliance.

Skills

Nursing experience

Auditing principles

Knowledge of CPT/HCPCS and ICD-9 coding

Provider Manuals knowledge

Investigative skills

Education

AS in nursing

BA/BS preferred

Job description

Anticipated End Date: 2026-01-12

Position Title: Nurse Auditor Senior – Payment Integrity Complex and Clinical Audit

Location: This role is fully virtual with required in-person training sessions. Applicants must reside within a reasonable commuting distance if hybrid onsite is requested. Candidates outside commuting distance are not considered unless accommodation is granted by law.

How you will make an impact:

• Investigate potential fraud and over-utilization through prepayment claims review and post payment auditing.
• Correlate review findings with appropriate actions: provider education, cost avoidance, sanctions or other actions.
• Assist with development of audit tools, policies, procedures and educational materials.
• Act as liaison with service operations and other areas regarding claims reviews and status.
• Analyze and trend performance data, collaborating with operations to improve processes and compliance.
• Notify areas of identified problems or providers, recommending modifications to medical policy and online policy edits.

Minimum Requirements:

• AS in nursing and minimum 4 years of clinical nursing experience; or equivalent combination of education and experience.
• Current unrestricted RN license in applicable state(s) required.

Preferred Skills, Capabilities, and Experiences:

• Knowledge of auditing, accounting and control principles and CPT/HCPCS, ICD-9 coding and medical policy guidelines strongly preferred.
• BA/BS preferred.
• Medical claims review with prior health care fraud audit/investigation experience preferred.
• Knowledge of Provider Manuals and Reimbursement policies is preferred.

Job Level and Workshift:

Job Level: Non-Management Exempt

Workshift: 1st Shift (United States of America)

EEO Statement:

Elevance Health is an Equal Employment Opportunity employer. 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. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws.