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Nurse Auditor
Elevance Health. Identify, monitor, and analyze aberrant patterns of utilization and/or fraudulent activities by health care providers .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in health care fraud investigation, including auditing and claims review, while effectively collaborating with service operations to implement corrective actions. Proficient in medical coding and policy guidelines, ensuring compliance and accuracy in health care practices.
Highest-signal resume keywords
Clinical Nursing ExperienceRN LicenseMedical Claims ReviewCPT/HCPCS CodingHealth Care Fraud Investigation
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Auditing PrinciplesFraud DetectionClaims ReviewCost AvoidanceProvider EducationRecovery of MoniesICD 9 CodingMedical Policy Guidelines
Soft Skills
Analytical SkillsCommunicationProblem-Solving
Certifications & Qualifications
Professional Coder Certification
Industry Keywords
Health Care FraudUtilization ReviewPrepayment Claims ReviewPost-Payment AuditingProvider Sanctions
About the role
Key responsibilities & impact- Identify, monitor, and analyze aberrant patterns of utilization and/or fraudulent activities by health care providers
- Investigate potential fraud and over-utilization through prepayment claims review and post-payment auditing
- Correlate review findings with appropriate actions, including provider education, recovery of monies, cost avoidance, and recommending sanctions or other actions
- Liaise with service operations and other company areas regarding claims reviews and their status
- Notify relevant areas of identified problems or providers
- Recommend modifications to medical policy and online policy edits
Requirements
What you’ll need- Associate degree in nursing and minimum of 2 years of clinical nursing experience; or equivalent combination of education and experience
- Current unrestricted RN license in applicable state(s) required
- BA/BS preferred
- Certification as a Professional Coder preferred
- Knowledge of auditing, accounting and control principles strongly preferred
- Working knowledge of CPT/HCPCS and ICD 9 coding and medical policy guidelines strongly preferred
- Medical claims review experience with prior health care fraud audit/investigation experience preferred
- Candidates must be within a reasonable commuting distance from the posting location(s), unless an accommodation is granted as required by law
- COVID-19 and Influenza vaccination required for certain patient/member-facing roles unless an acceptable explanation is provided
Benefits
Comp & perks- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical benefits
- Dental benefits
- Vision benefits
- Short-term disability benefits
- Long-term disability benefits
- 401(k) match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
- Virtual full-time work, except for required in-person training sessions
- Accommodation for virtual-work commuting-distance requirements as required by law