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Anthem Nurse Audit Sr PS25894 in Long Beach, California

Nurse Audit Sr PS25894

Location: Norfolk, Virginia, United States

Requisition #: PS25894

Post Date: Aug 15, 2019

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.

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.

Responsible for conducting Clinical DRG Validation reviewson pre-payment and post payment claims by auditing the submitted medical records.

Primary duties may include, but are not limited to:

  • Verifying that the billed diagnosis codes, procedure codes, and discharge status codes are documented as well as clinically supported.

  • 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.

  • Collaborate with service operations to improve processes and compliance. Identifies claim and review issues, recommending modifications to policies.

Requires current RN license in applicable state(s)with knowledge of navigating through a medical record for auditing purposes, as well as a working knowledge of CPT/HCPCS, ICD-9/ICD-10 coding, and medical policy guidelines as it applies to inpatient clinical validation DRG review. Certification as a Professional Coder preferred.

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

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