Clinical Provider Auditor II

Location: The ideal candidate will live within 50 miles of one of our pulse point locations and will work on a hybrid work model (1-2 days per week in the office).

The Clinical Provider Auditor is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.

How you will make an impact:

Examines claims for compliance with relevant billing and processing guidelines and identifies opportunities for fraud and abuse prevention and control.

Reviews and conducts analysis of claims and medical records prior to payment and uses required systems/tools to accurately document determinations and continue to the next step in the claim’s lifecycle.

Research new healthcare-related questions as necessary to aid in investigations and stay abreast of current medical coding and billing issues, trends, and changes in laws/regulations.

Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern.

Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation.

Assists with training of new associates.

Minimum Requirements:

Requires a AA/AS and minimum of 4 years medical coding/auditing experience, including minimum of 1 year in fraud, waste abuse experience; or any combination of education and experience, which would provide an equivalent background.

Requires coding certification (CPC, CCS, CPMA).

Preferred Qualifications, Skills, and Experiences:

Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology and bachelor's degree strongly preferred.For candidates working in person or remotely in the below location(s), the salary* range for this specific position is $58,800 to $105,840.

Locations: California; Colorado; District of Columbia (Washington, DC), Jersey City, NJ; Nevada; New York; Washington State

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws .

The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.