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Anthem, Inc. Nurse Auditor/Nurse Auditor Sr- RN in Pembroke Pines, Florida

Description

SHIFT: Day Job

SCHEDULE: Full-time

Be 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-Florida

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