Remote Clinical Provider Claims Auditor

Elevance Health; Atlanta (GA); Hybrid; USD 65,000 - 90,000; Full time

Job summary

Elevance Health seeks a Clinical Provider Auditor I to identify issues posing potential fraud and abuse. The role analyzes claims, reviews medical records prior to payment, and documents determinations in our systems. You will collaborate with the Special Investigation Unit and advise on risk interventions.

The position requires an AA/AS and at least 1 year of medical coding/auditing experience, with certification due within a year. Hybrid/virtual work with in-person onboarding is offered.

Qualifications

• Requires an AA/AS and minimum of 1 year related medical coding/auditing experience; or any combination of education and experience, which would provide an equivalent background.
• 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 using required systems/tools.
• Researches new healthcare questions to aid investigations and stays current with 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 interventions for loss control and risk avoidance based on investigation outcomes.

Skills

ICD-10 knowledge

CPT/HCPC knowledge

Medical coding

Fraud detection

Education

AA/AS degree

Job description

Elevance Health seeks a Clinical Provider Auditor I to identify issues posing potential fraud and abuse. The role analyzes claims, reviews medical records prior to payment, and documents determinations in our systems. You will collaborate with the Special Investigation Unit and advise on risk interventions.

The position requires an AA/AS and at least 1 year of medical coding/auditing experience, with certification due within a year. Hybrid/virtual work with in-person onboarding is offered.