Clinical Provider Auditor Senior - IntegritySIU

Position Title:

Clinical Provider Auditor Senior – Payment Integrity SIU

Location:

This role requires associates to be in‑office 1‑2 days per week, fostering collaboration and connectivity while providing flexibility for virtual work. Alternate locations may be considered for candidates residing within a reasonable commuting distance from an office.

Work Shift:

1st Shift (United States)
Job Level: Non‑Management Exempt Anticipated End Date:

• Examines claims for compliance with billing and processing guidelines and identifies opportunities for fraud and abuse prevention and control.
• Reviews and conducts analysis of claims and medical records prior to payment and uses required systems/tools to document determinations accurately.
• Researches new healthcare‑related questions as necessary to aid in investigations and stays abreast of current medical coding and billing issues, trends, and regulatory changes.
• Collaborates with the Special Investigation Unit and other internal areas to determine patterns of billing behavior.
• Recommends possible interventions for loss control and risk avoidance based on investigation outcomes.
• Trains new associates.
• Develops, designs, and implements new or revised methods to improve operations.

• Associate’s degree in a related field (AA/AS) and a minimum of 5 years of medical coding/auditing experience, including at least 4 years in fraud, waste, abuse.
• Equivalency between education and experience that provides an equivalent background.
• Required coding certification (CPC, CCS, CPMA).
• Preferred:
  Prepay review of Medicare and Medicaid experience, knowledge of ICD‑10 and CPT/HCPC coding guidelines, and a Bachelor’s degree.

This position is exempt and does not involve management responsibilities. The role enables 1‑st shift work and requires on‑site presence 1‑2 days per week, with remote work accommodation for eligible candidates.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.