Clinical Provider Auditor II

The Elevance Health Companies, Inc.; Atlanta (GA); Hybrid; USD 75,000 - 105,000; Full time

Job summary

Elevance Health is seeking a Clinical Provider Auditor II in Atlanta, GA, with a focus on identifying fraud and abuse in claims. The role allows virtual full-time work with necessary in-person training, under a hybrid policy requiring occasional onsite presence within commuting distance.

The position emphasizes examining claims for compliance, pre-payment analysis, and collaboration with the Special Investigation Unit to mitigate risk.

Qualifications

• Requires AA/AS and 3+ years medical coding/auditing experience, incl. 1 year in fraud, waste & abuse.
• Must have coding certifications: CPC, CCS, CPMA.
• Knowledge of ICD-10 and CPT/HCPCS coding guidelines.
• Bachelor's degree strongly preferred.

Responsibilities

• Examines claims for compliance with billing guidelines and identifies fraud/abuse opportunities.
• Reviews/analyzes claims and medical records before payment; documents determinations.
• Researches healthcare-related questions to aid investigations and stays updated on coding issues.
• Collaborates with Special Investigation Unit and other internal areas on mutual concerns.
• Recommends interventions for loss control and risk avoidance based on investigations.
• Assists with training of new associates.

Skills

Medical auditing

Fraud awareness

ICD-10 knowledge

Education

AA/AS

Bachelor's degree (preferred)

Certification: CPC/CCS/CPMA

Job description

Anticipated End Date: 2026-10-08

Position Title: Clinical Provider Auditor II

Primary Location(s): Atlanta, GA

Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. 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 an accommodation is granted as required by law.

The Clinical Provider Auditor II 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 next step in the claims lifecycle.
• Researches new healthcare related questions as necessary to aid in investigations and stays 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 3 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 Skills Capabilities & Experiences

• Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology.
• Bachelors degree strongly preferred.

Job Level: Non-Management Exempt

Workshift:

Job Family: FRD > Audit

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.

Equal Employment Opportunity

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 following form: Accessibility Accommodation Request Form 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.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words — the job is posted until 3/13, not through 3/13.

Company Culture

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

Join our Talent Community and stay connected with company news, information, and future job opportunities.

Fueled by our bold purpose to improve the health of humanity, we are transforming from a traditional health benefits organization into a lifetime trusted health partner.Our nearly 100,000 associates serve approximately 100M+ people, at every stage of health. We address a full range of needs with an integrated whole health approach, powered by industry-leading capabilities and a digital platform for health.

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 following form: Accessibility Accommodation Request Form 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

Please visit the Contract Worker Community Page.

Elevance Health is an Equal Opportunity Employer/Disability/Veterans.