Clinical Provider Auditor II

Elevance Health; Grand Prairie (TX); Remote; USD 60,000 - 80,000; Full time

Job summary

A healthcare solutions organization seeks a Clinical Provider Auditor II to audit claims for fraud and compliance. This remote role offers flexibility and requires a minimum of 3 years of medical coding/auditing experience, along with relevant coding certifications. Ideal candidates will possess strong analytical skills and be well-versed in current coding guidelines.

Qualifications

• Minimum of 3 years medical coding/auditing experience.
• Experience in fraud, waste, and abuse.
• Knowledge of ICD-10 and CPT/HCPC coding guidelines.

Responsibilities

• Examine claims for compliance and fraud prevention.
• Analyze claims and medical records before payment.
• Collaborate with Special Investigation Unit.

Skills

Medical coding/auditing

Fraud prevention

Research skills

Education

AA/AS degree

Coding certification (CPC, CCS, CPMA)

Job description

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 and Experiences:

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

Work Environment:

This role enables associates to work virtually full-time, with the exception of 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.

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.