Role Description The Nurse Audit Senior - Operating Room 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.

• 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.

Qualifications

• 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.

Requirements

• Knowledge of auditing, accounting and control principles and a working knowledge of CPT/HCPCS and ICD 10 coding and medical policy guidelines strongly preferred.
• BA/BS preferred.
• Medical claims review with prior health care fraud audit/investigation experience preferred.
• Professional Coder Certification preferred.

Benefits

• Merit increases.
• Paid holidays.
• Paid Time Off.
• Incentive bonus programs (unless covered by a collective bargaining agreement).
• Medical, dental, vision benefits.
• Short and long term disability benefits.
• 401(k) + match.
• Stock purchase plan.
• Life insurance.
• Wellness programs.
• Financial education resources.