Remote Clinical Provider Auditor I - Fraud & Compliance

The Elevance Health Companies, Inc.; Atlanta (GA); Hybrid; USD 60,000 - 85,000; Full time

Job summary

Elevance Health is hiring a Clinical Provider Auditor I to identify issues that may pose risk related to fraud and abuse. The role supports virtual work with in-person training, and occasional office commuting within distance to an Elevance Health location.

Responsibilities include examining claims for compliance, reviewing medical records prior to payment, and collaborating with the Special Investigation Unit to optimize loss control and risk mitigation.

Qualifications

• AA/AS degree and minimum of 1 year related medical coding/auditing experience.
• Must achieve coding certification (CPC, CCS, CPMA) within one year of starting in this position.
• Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology strongly preferred.
• Experience in Behavioral Health preferred.

Responsibilities

• Examines claims for compliance with relevant billing and processing guidelines and identifies opportunities for fraud and abuse prevention and control.
• Reviews and analyzes claims and medical records prior to payment and documents determinations in required systems/tools.
• Researches new healthcare questions to aid investigations and stays up-to-date on coding/billing changes in laws/regulations.
• Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern.
• Recommends interventions for loss control and risk avoidance based on investigation outcomes.

Skills

Medical coding

Auditing

Fraud awareness

Healthcare regulations

Education

AA/AS degree

Job description

Elevance Health is hiring a Clinical Provider Auditor I to identify issues that may pose risk related to fraud and abuse. The role supports virtual work with in-person training, and occasional office commuting within distance to an Elevance Health location.

Responsibilities include examining claims for compliance, reviewing medical records prior to payment, and collaborating with the Special Investigation Unit to optimize loss control and risk mitigation.