Provider Auditor Senior

This position will work a hybrid model (remote and office), 1-2 times per week. The Ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.

Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending.

The Provider Auditor Senior conducts on-site reviews of medical charts, medical notes, itemized bills and providers contracts to ensure that a claim is paid in accordance with the contract, provider reimbursement policies, and industry standards.

How you will make an impact:

Selects providers to be reviewed based on historical results of other reviews with providers, network management input and dollar volume of provider.

Schedules review with provider, analyzes data to select claims to be reviewed, conducts review using medical charts, medical notes, itemized bills and provider contracts.

Conducts exit interview with provider management team by presenting preliminary review results.

Verifies dollar amount on claim is correct in claims system and writes report of the findings of the review and requests payments for any overpayments.

Identifies aberrant patterns of billing and detects potential abuse. Mentors and trains Provider Auditor as needed.

Drafts department policies and procedures and other educational materials.

Works on task forces and committees representing functional area.

Minimum Requirements:

Requires either a BA/BS degree, medical coding certification and a minimum of 3 years equivalent work experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

RN experience a plus.

Provider contract experience a plus.

Claims experience preferred.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and 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, or local laws. Applicants who require accommodation to participate in the job application process may contact [email protected] for assistance.