Anthem Nurse Audit Sr. - Remote - PS18157 in Columbia, South Carolina

Nurse Audit Sr. - Remote - PS18157

Location: United States


Field: Medical

Requisition #: PS18157

Post Date: 4 days ago

Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care. This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health benefits companies and a Fortune Top 50 Company.

The Nurse Audit Sr. is 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

  • Requires an AS/BS in nursing and 4 years of clinical nursing experience; or any combination of education and experience, which would provide an equivalent background.

  • Current unrestricted state RN license is required.

  • Knowledge of auditing, a working knowledge of CPT/HCPCS and ICD 9 and ICD 10 coding and medical policy guideline is required, however certification is preferred.

  • Working Knowledge of DRG Validation preferred.

  • BA/BS preferred.

  • Medical claims review with prior health care audit experience preferred.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 Diversity Inc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran.