Nurse Auditor Senior - Integrity Complex and Clinical Audit

Nurse Auditor Senior - Payment Integrity Complex and Clinical Audit

Join to apply for the Nurse Auditor Senior - Payment Integrity Complex and Clinical Audit role at Elevance Health

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. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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.

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• Investigates potential fraud and over‑utilization by performing medical reviews via preALANY 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

• Requires an 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 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

Mid‑Senior level

Full‑time

Accounting/Auditing and Finance

Accounting

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.

Elevance Health 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 elevancehealthj for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.