Job Description
Location: The ideal candidate will live within 50 miles of one of our pulse point locations and will work on a hybrid work model (1-2 days per week in the office).
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 Lead is responsible for leading a team of clinicians responsible for identifying, monitoring, and analyzing aberrant patterns of utilization and/or fraudulent activities by healthcare providers through prepayment claims review, post-payment auditing, and provider record review.
How You Will Make An Impact
• Develops, maintains, and enhances the claims review process.
• Assists management with developing unit goals, policies, and procedures.
• Investigates potential fraud and over-utilization by performing the most complex 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 principal liaison with Service Operations as well as other areas of the corporation relative to claims reviews and their status.
• Notifies areas of identified problems or providers, recommending modifications to medical policy, and 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.
• Trains and provides guidance to nurse auditors and manages workflow and priorities for the unit.
• Travels to worksite and other locations as necessary.
Minimum Requirements
• Requires AS in nursing and minimum of 5 years of clinical experience and minimum of 2 years of claims review 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, Qualifications, And Experiences
• BA/BS preferred.
• Experience in hospital bill auditing or defense auditing strongly preferred.
• Experience with provider manuals and reimbursement policies highly desired.
• Certification as a Professional Coder highly preferred.
• Knowledge of auditing, accounting, and control principals and working knowledge of CPT/HCPCS and ICD 10 coding and medical policy guidelines strongly preferred.
• Prior health care fraud audit/investigation experience preferred.
For candidates working in person or remotely in the below location(s), the salary range for this specific position is $83,412 to $142,++2.
Locations: California; Colorado; District of Columbia (Washington, DC); Maryland; Nevada; New York; Washington State
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.
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, and 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 and 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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
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-1+. 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, ****** 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 elevancehealthjobssupport@elevancehealth.com for assistance.
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 Lead is responsible for leading a team of clinicians responsible for identifying, monitoring, and analyzing aberrant patterns of utilization and/or fraudulent activities by healthcare providers through prepayment claims review, post-payment auditing, and provider record review.
How You Will Make An Impact
• Develops, maintains, and enhances the claims review process.
• Assists management with developing unit goals, policies, and procedures.
• Investigates potential fraud and over-utilization by performing the most complex 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 principal liaison with Service Operations as well as other areas of the corporation relative to claims reviews and their status.
• Notifies areas of identified problems or providers, recommending modifications to medical policy, and 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.
• Trains and provides guidance to nurse auditors and manages workflow and priorities for the unit.
• Travels to worksite and other locations as necessary.
Minimum Requirements
• Requires AS in nursing and minimum of 5 years of clinical experience and minimum of 2 years of claims review 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, Qualifications, And Experiences
• BA/BS preferred.
• Experience in hospital bill auditing or defense auditing strongly preferred.
• Experience with provider manuals and reimbursement policies highly desired.
• Certification as a Professional Coder highly preferred.
• Knowledge of auditing, accounting, and control principals and working knowledge of CPT/HCPCS and ICD 10 coding and medical policy guidelines strongly preferred.
• Prior health care fraud audit/investigation experience preferred.
For candidates working in person or remotely in the below location(s), the salary range for this specific position is $83,412 to $142,++2.
Locations: California; Colorado; District of Columbia (Washington, DC); Maryland; Nevada; New York; Washington State
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.
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, and 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 and 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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
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-1+. 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, ****** 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 elevancehealthjobssupport@elevancehealth.com for assistance.
💡 Quick Summary
Seeking a career-building opportunity? The Nurse Audit Lead | Carelon Payment Integrity position is now open for candidates interested in the Health Jobs sector. This role in Denver offers a professional environment and growth potential.
Requirement Snapshot: Candidates should possess basic communication skills, a proactive attitude, and the ability to work in a team. Experience in Health Jobs is a plus.
