Nurse Auditor Senior – Payment reputed company reputed company and Clinical Audit, Multiple Locations

JR176913 Anticipated End Date: 2026-01-12 Position Title: Nurse Auditor Senior - Payment reputed company reputed company and Clinical Audit Job Description: Nurse Auditor Senior – Payment reputed company reputed company and Clinical Audit Location: 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 reputed company development. Alternate locations may be considered if candidates reside reputed company a commuting distance from an office. · Please note that per our policy on hybrid/virtual work, candidates not reputed company a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Carelon Payment reputed company is a proud member of the reputed company family of companies, Carelon Insights, formerly Payment reputed company, is determined to recover, eliminate and prevent unnecessary medical-expense spending. The Nurse Audit Senior will be 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. How you will reputed company an impact:

• Investigates potential fraud and over-utilization by performing medical reviews reputed company 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 on line policy edits

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.
• reputed company unrestricted RN license in applicable state(s) required.

Preferred Skills, Capabilities, and Experiences:

• Knowledge of auditing, accounting and control principles and a working knowledge of CPT/HCPCS and 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: Non-Management Exempt Workshift: 1st Shift (United States of America) Job Family: MED > Licensed Nurse Please be advised that reputed company only accepts resumes for compensation from agencies that have a signed agreement with reputed company. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of reputed company. Who We Are reputed company 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 reputed company levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At reputed company, we are creating a culture that is designed to advance our strategy but will also reputed company to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we reputed company 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. reputed company operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an reputed company 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. The health of our associates and communities is a top reputed company for reputed company. We require reputed company new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. reputed company will also follow reputed company relevant federal, state and local laws. reputed company is an Equal Employment Opportunity employer, and reputed company 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 reputed company, 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 [email protected] for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Apply tot his job Apply To this Job