Claims Auditor Senior

Location: Saint Paul

Claims Auditor Senior

Hybrid 1: This role requires associates to be in-office 1 day per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Claims Auditor Senior is responsible for pre and post payment and adjudication audits of high dollar claims across multiple lines of business, claim types and products including complex specialized claims within Service Experience. Serves as the subject matter expert for the unit.

How you will make an impact:

• Performs audits of and may adjudicate complex high dollar claims while maintaining acceptable levels of claims inventory and age.
• Ensures claim payment accuracy by verifying various aspects of the claim including eligibility, system coding and pricing, pre-authorization, and medical necessity.
• Contacts others to obtain any necessary information.
• Completes and maintains detailed documentation of audit which includes decision methodology, system or processing errors, and monetary discrepancies which are used for financial reporting and trending analysis.
• Provides feedback on claims processing errors; identifies quality improvement opportunities and initiates complex system requests related to coding or system issues.
• Refers over payment opportunities to Recovery Team.
• Serves as a subject matter expert for Policy and Clinical Guidelines.
• Associates at this level serve as a mentor and resource to other audit staff.
• Must possess strong research and problem solving skills.

Minimum Requirements

• HS diploma or GED.
• Minimum of 4 years related experience in a quality audit capacity (preferably in healthcare or insurance sector); or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences

• Working knowledge of insurance industry and medical terminology; detailed knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines strongly preferred.
• Ability to acquire and perform progressively more complex skills and tasks in a production environment strongly preferred.
• BA/BS degree or RN preferred.
• Stop loss background, no stop loss claims auditing background experience preferred.

For candidates working in person or virtually in the below location(s), the salary
* range for this specific position is $22.70/hr to $37.44/hr.

Locations:
Minnesota, Virginia

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations.

No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to…