Clinical Provider Auditor II — Remote Fraud & Compliance

Elevance Health; Atlanta (GA); Remote; USD 75,000 - 105,000; Full time

Benefits offered by this job

Health insurance

401(k) match

Stock purchase plan

Life insurance

Wellness programs

Job summary

Elevance Health seeks a Clinical Provider Auditor II to identify potential fraud and abuse in claims and medical records, ensuring adherence to billing guidelines and processing standards. This role emphasizes auditing accuracy and risk identification.

Responsibilities include reviewing claims prior to payment, documenting determinations, staying updated on coding changes, and collaborating with the Special Investigation Unit to implement loss-control interventions and training for new

Qualifications

• 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 providing an equivalent background.
• Requires coding certification (CPC, CCS, CPMA).

Responsibilities

• 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.

Skills

Medical coding

Auditing

Fraud, waste & abuse experience

Education

AA/AS degree

Job description

Elevance Health seeks a Clinical Provider Auditor II to identify potential fraud and abuse in claims and medical records, ensuring adherence to billing guidelines and processing standards. This role emphasizes auditing accuracy and risk identification.

Responsibilities include reviewing claims prior to payment, documenting determinations, staying updated on coding changes, and collaborating with the Special Investigation Unit to implement loss-control interventions and training for new