Nurse Audit Senior - Operating Room

Position Title Nurse Audit Senior – Operating Room Location & Shift Virtual: Full‑time days, Monday‑Friday (EST/CST). Optional in‑person training and required onsite visits. Alternate locations considered if candidate lives within reasonable commuting distance from an office. Work Shift: 1st Shift (United States of America) Job Description The Nurse Audit Senior – Operating Room is responsible for identifying, monitoring, and analyzing aberrant patterns of utilisation and/or fraudulent activities by health care providers through prepayment claims review, post‑payment auditing, and provider record review. Responsibilities Investigate potential fraud and over‑utilisation by performing medical reviews via prepayment claims review and post‑payment auditing. Correlate review findings with appropriate actions (provider education, recovery of monies, cost avoidance, recommending sanctions or other actions). Assist with development of audit tools, policies and procedures and educational materials. Act as liaison with service operations and other company areas regarding claims reviews and status. Analyse and trend performance data, working with service operations to improve processes and compliance. Notify areas of identified problems or providers, recommending modifications to medical policy and online policy edits. Communicate and negotiate with providers selected for prepayment review. Assist investigators by providing medical review expertise to detect fraudulent activities. Serve as a resource to nurse auditors. Minimum Qualifications Bachelor of Science in Nursing or equivalent; requires a Registered Nurse (RN) licence in applicable state(s) with unrestricted status. Minimum 4 years of clinical nursing experience, or equivalent combination of education and experience. Preferred Skills & Experience Broad understanding of operating‑room roles and procedures; operating‑room circulator experience preferred. Knowledge of auditing, accounting and control principles and working knowledge of CPT/HCPCS and ICD‑9 coding and medical policy guidelines. Ability to travel to worksite and other locations as necessary. Bachelor’s or Master’s degree in Nursing, Healthcare Administration, or related field preferred. Medical claims review with prior health‑care fraud audit/investigation experience preferred. Certification as a Professional Coder preferred. Job Details Job Level: Non‑Management Exempt Job Family: MED – Licensed Nurse Legal & Equal Opportunity Statement Elevance Health is an Equal Employment Opportunity employer. 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, and local laws. Applicants requiring accommodation to participate in the job application process may contact View email address on click.appcast.io 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. Prospective employees required to be screened under Florida law should review the resources at HB531 – Florida Agency for Health Care Administration. #J-18808-Ljbffr