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Anthem, Inc. Nurse Audit Sr. in Winston Salem, North Carolina


SHIFT: Day Job

SCHEDULE: Full-time

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.

Location: This is a full time remote position and can work anywhere in the US.

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. Primary 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 including provider education and recovery of monies.

  • 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.

  • Perform post payment audit of submitted medical records.

  • Serves as resource to nurse auditors


  • Requires an AS/BS in nursing and 4 years of clinical nursing experience; or any combination of education and experience, which would provide an equivalent background.

  • Current unrestricted state RN license is required.

  • Requires knowledge of navigating through a medical record for auditing purposes, a working knowledge of CPT/HCPCS and ICD- 9 and ICD-10 coding, and medical policy guidelines as it applies to inpatient clinical validation DRG review.

  • BA/BS preferred

  • Medical claims review with prior health care audit experience preferred

  • Certification as a Professional Coder preferred.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.