Clinical Provider Auditor II

Elevance Health; Durham (NC); Hybrid; USD 70,000 - 95,000; Full time

Benefits offered by this job

Merit increases

Paid holidays

Paid Time Off

Incentive bonus

Medical

Dental

Vision

Disability coverage

401(k) match

Stock plan

Life insurance

Wellness programs

Financial education resources

Job summary

Elevance Health is seeking a Clinical Provider Auditor II to identify risk and ensure compliant billing practices. The role emphasizes fraud prevention through claims and medical record review, with opportunities to collaborate across the organization.

The ideal candidate will have coding certifications and experience in fraud/waste/abuse investigations, plus knowledge of ICD-10 and CPT/HCPC guidelines. Hybrid work model and in-person training may apply.

Qualifications

• AA/AS degree required with 3+ years in medical coding/auditing.
• 1 year in fraud, waste and abuse investigations.
• CPC, CCS or CPMA certification required.

Responsibilities

• Examine claims for compliance and identify fraud risk opportunities.
• Review claims and medical records before payment and document determinations.
• Research healthcare questions to aid investigations and track coding issues.
• Collaborate with Special Investigation Unit on mutual concerns.
• Recommend interventions for loss control and risk avoidance.
• Assist in training new associates.

Skills

Fraud & abuse

Medical coding

ICD-10 CPT

Audit investigations

Communication skills

Education

AA/AS degree

3+ years coding/auditing

Bachelor's degree preferred

Tools

CPC certification

CCS certification

CPMA certification

Job description

Clinical Provider Auditor II

Primary Location(s): Atlanta, GA

Virtual: This role enables associates to workvirtually 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 candidatesresidewithin 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, unlessan accommodationis 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.

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
• 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
• financial education resources

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 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.