Nurse Audit Senior (Operating Room)

Anticipated End Date:

2025-10-10

Position Title:

Nurse Audit Senior (Operating Room)

Job Description:

Nurse Audit Senior (Operating Room)

Virtual:  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 skill development.

• Please note that per our policy on hybrid/virtual work, candidates not within 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 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 Senior 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.

How you will make an impact:

• 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 online 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. 

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.

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

Preferred Skills, Capabilities and Experiences:

• Operating room and/or auditing experience highly preferred.

• Medical claims review with prior health care fraud audit/investigation experience highly preferred.

• Knowledge of auditing, accounting and control principles and a working knowledge of CPT/HCPCS and ICD 10 coding and medical policy guidelines strongly preferred.

• Travels to worksite and other locations as necessary.

• BA/BS preferred.

• Certification as a Professional Coder preferred.

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $82,192 to $123,288.

Locations: Colorado

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 b