Remote Clinical Provider Auditor II – Fraud & Compliance

The Elevance Health Companies, Inc.; Atlanta (GA); Hybrid; USD 75,000 - 105,000; Full time

Job summary

Elevance Health is seeking a Clinical Provider Auditor II in Atlanta, GA, with a focus on identifying fraud and abuse in claims. The role allows virtual full-time work with necessary in-person training, under a hybrid policy requiring occasional onsite presence within commuting distance.

The position emphasizes examining claims for compliance, pre-payment analysis, and collaboration with the Special Investigation Unit to mitigate risk.

Qualifications

• Requires AA/AS and 3+ years medical coding/auditing experience, incl. 1 year in fraud, waste & abuse.
• Must have coding certifications: CPC, CCS, CPMA.
• Knowledge of ICD-10 and CPT/HCPCS coding guidelines.
• Bachelor's degree strongly preferred.

Responsibilities

• Examines claims for compliance with billing guidelines and identifies fraud/abuse opportunities.
• Reviews/analyzes claims and medical records before payment; documents determinations.
• Researches healthcare-related questions to aid investigations and stays updated on coding issues.
• Collaborates with Special Investigation Unit and other internal areas on mutual concerns.
• Recommends interventions for loss control and risk avoidance based on investigations.
• Assists with training of new associates.

Skills

Medical auditing

Fraud awareness

ICD-10 knowledge

Education

AA/AS

Bachelor's degree (preferred)

Certification: CPC/CCS/CPMA

Job description

Elevance Health is seeking a Clinical Provider Auditor II in Atlanta, GA, with a focus on identifying fraud and abuse in claims. The role allows virtual full-time work with necessary in-person training, under a hybrid policy requiring occasional onsite presence within commuting distance.

The position emphasizes examining claims for compliance, pre-payment analysis, and collaboration with the Special Investigation Unit to mitigate risk.