Claims Auditor Lead

Elevance Health; Miami (FL); Hybrid; USD 90,000 - 130,000; Full time

Job summary

Elevance Health is seeking a Claims Auditor Lead to manage high-dollar claim audits within Service Operations. The role includes pre- and post-payment audits, training new hires, and developing staff while ensuring adherence to policies and procedures.

The position supports a hybrid work arrangement with in-office collaboration and requires strong leadership to drive accuracy and efficiency in complex claim reviews.

Qualifications

• Requires HS diploma or GED and a minimum of 6 years related experience in a quality audit capacity (preferably in healthcare or insurance).
• Proficiency in Microsoft Office Suite is highly preferred.
• Commercial Claims experience is highly preferred.
• CI&W and WGS experience is highly preferred.

Responsibilities

• Owns and leads audits for high-dollar claims and complex scenarios.
• Trains and mentors team members, supporting new hires and skill development.
• Reviews and maintains quality and productivity records for the unit.
• Interprets contracts and prepares monthly reports as a subject matter expert.

Skills

Quality auditing

Leadership

Training & mentoring

Policy interpretation

Education

HS diploma or GED

Tools

CI&W

WGS

Job description

Claims Auditor Lead

Hybrid 1: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

The Claims Auditor Lead is responsible for processing high dollar claims within Service Operations. Responsible for pre and post payment and adjudication audits of high dollar medical and pharmacy. Serves as the subject matter expert for the unit.

Primary duties may include, but are not limited to:

• Responsible for all team training including but not limited to new hires, cross training, new product and system enhancements.

• Conducts audits for new hires and/or any team member learning a new skill.

• Reviews, interprets and maintains records of quality and productivity for entire team.

• Coaches, mentors and develops associates to ensure processes, guidelines and tools are utilized correctly.

• Utilizes inventory management strategies to monitor priorities and ensure timely turnaround of all claims.

• Responsible for creating, updating and maintaining departmental policy and claims auditor procedure manuals for accuracy.

• Independently analyzes and makes decisions on complex claim audit issues.

• Serves as subject matter expert on policy, workflow and technical questions.

• Interfaces with all levels of support including but not limited to production support, medical management, provider /vendor contracting and other audit teams.

• Partners with Management on complex claims reviews and resolution.

• Responsible for reviewing and resolving shared mailbox issues.

• Interprets contracts, prepares monthly reports, and attends meetings as subject matter expert when requested.

• Manages projects as assigned and may work across different platforms or lines of business.

• Reviews and responds to external audit requests.

• Performs audit reviews of and may adjudicate complex high dollar claims by completing an end to end audit with final approval authority.

Minimum Requirements:

Requires a HS diploma or GED and a minimum of 6 years related experience in a quality audit capacity (preferably in healthcare or insurance sector); or any combination of education and experience which would provide an equivalent background.

Preferred Requirements:

• Proficiency in Microsoft Office Suite is highly preferred.

• Commercial Claims experience is highly preferred

• CI&W and WGS experience is highly preferred.

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.

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 and Influenza. 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 should submit the Accessibility Accommodation Request Form (https://forms.cloud.microsoft/pages/responsepage.aspx?id=8giMvgesLESaRuvu61vU17EJaA0EP3FIissI8zmZ_NpUNUgyTFRUMkY5NE5JNDFWMkhaUzQxMkJLWS4u&route=shorturl) and a member of the team will be in contact.

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 education and awareness resources at HB531 | Florida Agency for Health Care Administration (https://info.flclearinghouse.com/).