Nurse Audit Senior Operating Room

Nurse Audit Senior Operating Room

Shift: Days, Monday-Friday, EST/CST

Location: Virtual: This role enables associates to work virtually full-time, except for 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.

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.

How you will make an impact:

• 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.

Minimum 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.

Preferred Skills, Capabilities and Experiences:

• Broad understanding of OR roles and procedures, highly preferred.
• Operating room Circulator experience, highly preferred.
• Knowledge of auditing, accounting and control principles and a working knowledge of CPT/HCPCS and ICD 9 coding and medical policy guidelines strongly preferred.
• Ability to travel to worksite and other locations as necessary.
• BA/BS preferred.
• Medical claims review with prior health care fraud audit/investigation experience preferred.
• Certification as a Professional Coder preferred.

Job Level: Non-Management Exempt

Workshift: 1st Shift (United States of America)

Job Family: MED > Licensed Nurse