Remote Nurse Audit Specialist — Fraud & Claims Review

Elevance Health (Anthem); Mason (OH); Hybrid; USD 70,000 - 95,000; Full time

Job summary

Elevance Health is seeking a Nurse Audit professional to identify and analyze aberrant utilization and potential fraud through prepayment and post-payment claims reviews. You will monitor patterns, correlate findings with actions, and collaborate with service operations to enhance claims integrity and cost control.

The role requires an AS in nursing with an active RN license and 2+ years of clinical nursing experience; CPT/HCPCS and ICD-9 knowledge is highly valued.

Qualifications

• Requires AS in nursing and RN license in applicable state(s).
• Experience with medical claims reviews and fraud audit preferred.
• Knowledge of CPT/HCPCS and ICD-9 coding strongly preferred.

Responsibilities

• Identify aberrant utilization and potential fraud through prepayment and post-payment audits.
• Correlate findings with actions such as provider education, recovery of monies and sanctions.
• Act as liaison with service operations regarding claims reviews and status.
• Notify areas of identified problems and suggest policy edits.

Skills

Nurse auditing

Fraud investigation

Provider education

Claims review

Education

AS in nursing

RN license

BA/BS preferred

Job description

Elevance Health is seeking a Nurse Audit professional to identify and analyze aberrant utilization and potential fraud through prepayment and post-payment claims reviews. You will monitor patterns, correlate findings with actions, and collaborate with service operations to enhance claims integrity and cost control.

The role requires an AS in nursing with an active RN license and 2+ years of clinical nursing experience; CPT/HCPCS and ICD-9 knowledge is highly valued.