Clinical Provider Auditor II

Elevance Health; Richmond (VA); Hybrid; USD 65,000 - 85,000; Full time

Job summary

Elevance Health is seeking a Clinical Provider Auditor II who will work virtually full-time, examining claims for compliance and fraud prevention. This role requires a minimum of 4 years in medical coding and auditing, with strong analytical skills and attention to detail essential for identifying risks and collaborating on investigations.

Benefits

Merit increases and bonuses

Paid Time Off and holidays

401(k) with company match

Wellness programs

Financial education resources

Qualifications

• Requires a AA/AS and minimum of 4 years medical coding/auditing experience.
• Requires coding certification (CPC, CCS, CPMA).
• Knowledge of ICD-10 and CPT/HCPC coding guidelines preferred.

Responsibilities

• Examines claims for compliance with billing guidelines.
• Researches healthcare questions for fraud investigations.
• Collaborates with Special Investigation Unit on fraud cases.

Skills

Analytical Skills

Attention to Detail

Knowledge of Medical Coding

Education

AA/AS degree

Bachelor's degree (preferred)

Job description

Anticipated End Date:

2025-06-24

Position Title:

Clinical Provider Auditor II

Job Description:

Clinical Provider Auditor II

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

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 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 4 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 and Bachelors degree strongly preferred.
• Medical coding and auditing experience strongly preferred.

Job Level:

Non-Management Exempt

Workshift:

Job Family:

FRD > Audit

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.

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 may contact [e-mail] for assistance. 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.