Clinical Provider Auditor

Clinical Provider Auditor I

We prefer any of the following cities/States:
Woodland Hills, CA;
Denver, CO;
Miami, FL;
Tampa, FL;
Atlanta, GA;
Chicago, IL;
Grand Prairie, TX;
Seattle, WA.

This role requires associates to be in‑office 1 – 2 days 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 if candidates reside within a commuting distance from an office.

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 Clinical Provider Auditor I is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.

Primary duties may include, but are not limited to:

• Examines claims for compliance with relevant 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 accurately document determinations and continue to next step in the claims lifecycle.
• Researches new healthcare related questions as necessary to aid in investigations and stays abreast of current 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 possible interventions for loss control and risk avoidance based on the outcome of the investigation.

Requires a 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.

For candidates working in person or virtually in the below locations, the salary
* range for this specific position is $25.26/hr to $47.85

Location(s):
California, Colorado, Illinois, Washington State

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 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.

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