Senior Clinical Provider Auditor — Fraud & Compliance

Elevance Health; Mason (OH); Hybrid; USD 72,000 - 95,000; Full time

Benefits offered by this job

Medical

Dental

Vision

401(k) + match

Stock purchase plan

Life insurance

Wellness programs

Paid holidays

Paid Time Off

Incentive bonus programs

Job summary

Elevance Health, a Fortune 25 health company, seeks a Clinical Provider Auditor II in a hybrid/virtual role with in-person training. You will examine claims for fraud risk, review medical records pre-payment, and collaborate with the Special Investigation Unit to prevent loss and ensure compliance.

A minimum AA/AS plus 3 years in medical coding/audit is required, CPC/CCS/CPMA certs preferred. The role offers a hybrid work model and opportunities to train new staff while advancing risk management

Qualifications

• Requires an AA/AS and minimum of 3 years medical coding/auditing experience, including minimum of 1 year in fraud, waste abuse experience.
• 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 analyzes claims and medical records prior to payment and documents determinations in required systems/tools.
• Researches healthcare questions to aid in investigations and stays updated on 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.
• Assists with training of new associates.

Skills

Medical coding

Auditing

Fraud awareness

Regulatory knowledge

Education

AA/AS

Bachelor's degree preferred

Job description

Elevance Health, a Fortune 25 health company, seeks a Clinical Provider Auditor II in a hybrid/virtual role with in-person training. You will examine claims for fraud risk, review medical records pre-payment, and collaborate with the Special Investigation Unit to prevent loss and ensure compliance.

A minimum AA/AS plus 3 years in medical coding/audit is required, CPC/CCS/CPMA certs preferred. The role offers a hybrid work model and opportunities to train new staff while advancing risk management