Elevance Health is a healthcare and health insurance company building a broader, long-term approach to supporting people’s health. Its work combines health benefits, integrated whole-health services, and digital health capabilities designed to connect care and coverage more effectively. With a workforce of nearly 100,000 associates serving more than 118 million people, Elevance Health offers roles across a large, multidisciplinary organization focused on improving health outcomes, evolving the healthcare system, and supporting stronger communities.
Nurse Auditor
Review healthcare claims for potential fraud and overutilization at Elevance Health. Investigate providers and recommend recoveries, sanctions, and policy updates.
Description
- Identify and monitor unusual utilization patterns and potential provider fraud.
- Investigate suspected fraud and overutilization through prepayment claim reviews and post-payment audits.
- Use review findings to guide provider education, fund recovery, cost avoidance, and recommendations for sanctions or other action.
- Coordinate with service operations and other company teams on claim reviews and their status.
- Alert relevant teams to identified issues or providers.
- Recommend updates to medical policy and online policy edits.
Requirements
- Associate degree in nursing and at least two years of clinical nursing experience, or an equivalent combination of education and experience.
- Current unrestricted RN license in the applicable state or states.
- Bachelor’s degree preferred.
- Professional coder certification preferred.
- Strong preference for knowledge of auditing, accounting, and control principles.
- Strong preference for working knowledge of CPT/HCPCS and ICD-9 coding and medical policy guidelines.
- Medical claims review experience and prior healthcare fraud audit or investigation experience preferred.
- Candidates must live within reasonable commuting distance of the posting location unless a legally required accommodation is granted.
- COVID-19 and influenza vaccination is required for certain patient- or member-facing roles unless an acceptable explanation is provided.
Benefits
- Merit increases
- Paid holidays
- Paid time off
- Incentive bonus programs
- Medical benefits
- Dental benefits
- Vision benefits
- Short-term disability benefits
- Long-term disability benefits
- 401(k) matching
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
- Full-time virtual work, except for required in-person training sessions
- Accommodation for virtual-work commuting-distance requirements where required by law