Nurse Auditor/Nurse Auditor Sr- RN
Company: Anthem, Inc
Location: Savannah
Posted on: May 15, 2022
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Job Description:
Description SHIFT: Day JobSCHEDULE: Full-timeBe part of an
extraordinary team We are looking for leaders at all levels of the
organization who are passionate about making an impact on our
members and the communities we serve. You will thrive in a complex
and collaborative environment where you take action and ownership
to solve problems and lead change. Do you want to be part of a
larger purpose and an evolving, high-performance culture that
empowers you to make an impact? *This position is open to any U.S
state and eligible for full time work from home Job
Summary: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.Primary duties may
include, but are not limited to:+ Investigates potential fraud and
over-utilization by performing 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).+
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.+
Communicates and negotiates with providers selected for prepayment
review.+ Assists investigators by providing medical review
expertise to accomplish the detection of fraudulent activities.+
Serves as resource to nurse auditors.Qualifications Desired Skills
and Abilities:Nurse Auditor:+ Requires AS in nursing and minimum of
2 years of clinical nursing experience; or any combination of
education and experience, which would provide an equivalent
background.+ Current unrestricted RN license in applicable state(s)
required.+ Knowledge of auditing, accounting and control principles
and a working knowledge of CPT/HCPCS, ICD 10 and PCS coding and
medical policy guidelines strongly preferred.+ Some travel may be
required.+ BA/BS preferred.+ Medical claims review with prior
health care fraud audit/investigation experience preferred.+ One or
more of the following certifications are preferred: Certified
Clinical Documentation Specialist (CCDS), Certified Documentation
Improvement Practitioner (CDIP), or Inpatient Coding Credential
such as CCS or CIC. + Experience with third party Clinical
Validation Audits and/ or DRG Validation or inpatient clinical
documentation improvement experience preferred. Nurse Auitor Sr.+
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.+ Current unrestricted RN
license in applicable state(s) required.+ Knowledge of auditing,
accounting and control principles and a working knowledge of
CPT/HCPCS, ICD 10 and PCS coding and medical policy guidelines
strongly preferred.+ BA/BS preferred.+ Medical claims review with
prior health care fraud audit/investigation experience preferred.+
One or more of the following certifications are preferred:
Certified Clinical Documentation Specialist (CCDS), Certified
Documentation Improvement Practitioner (CDIP), or Inpatient Coding
Credential such as CCS or CIC.+ Experience with third party
Clinical Validation Audits and/ or DRG Validation or inpatient
clinical documentation improvement experience preferred. 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. The
health of our associates and communities is a top priority for
Anthem. We require all new candidates to become vaccinated against
COVID-19. If you are not vaccinated, your offer will be rescinded
unless you provide - and Anthem approves - a valid religious or
medical explanation as to why you are not able to get vaccinated
that Anthem is able to reasonably accommodate. Anthem will also
follow all relevant federal, state and local laws. Anthem, Inc. has
been named as a Fortune Great Place To Work in 2021, is ranked as
one of the 2021 World's Most Admired Companies among health
insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on
Diversity and Inclusion. To learn more about our company and apply,
please visit us at careers.antheminc.com. Anthem 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,
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 ability@icareerhelp.com for assistance.
REQNUMBER: PS73020-Georgia
Keywords: Anthem, Inc, Savannah , Nurse Auditor/Nurse Auditor Sr- RN, Accounting, Auditing , Savannah, Georgia
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