Nurse Audit-18738

WellPoint is the nation's leading health benefits company serving the needs of approximately 28 million medical members nationwide.

Responsible to identify, monitor and analyze aberrant patterns of utilization and/or fraudulent activities by health care providers through prepayment claims review and post payment auditing. Essential duties may include, but are not limited to: 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). Acts as liaison with service operations as well as other areas of the company relative to claims reviews and their status. Notifies appropriate 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. Performs other duties as assigned. .

Current licensure as a R.N. required and 2-3 years clinical nursing experience. BA/BS degree preferred. Experience should include medical claims review with prior health care fraud audit/investigation experience preferred. Certification as a Professional Coder preferred. Requires knowledge of auditing, accounting and control principles and a working knowledge of CPT/HCPCS and ICD 9 coding and medical policy guidelines. Excellent written/oral communication and organizational skills required. Demonstrated experience with personal computer and related software and strong research and analytical skills required. Some local or overnight travel required