Clinical Provider Auditor II

Clinical Provider Auditor II

Location
:
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.

Hybrid 1:
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 II is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.

• Examine claims for compliance with relevant billing and processing guidelines and identify opportunities for fraud and abuse prevention and control.
• Review and conduct analysis of claims and medical records prior to payment, and use required systems/tools to accurately document determinations and continue to the next step in the claims lifecycle.
• Research new healthcare‑related questions as necessary to aid in investigations and stay abreast of current medical coding and billing issues, trends and changes in laws/regulations.
• Collaborate with the Special Investigation Unit and other internal areas on matters of mutual concern.
• Recommend possible interventions for loss control and risk avoidance based on the outcome of the investigation.
• Assist with training of new associates.

Requires an AA/AS and a minimum of 3 years medical coding/auditing experience, including a minimum of 1 year in fraud, waste, abuse experience; or any combination of education and experience that provides an equivalent background. Requires coding certification (CPC, CCS, CPMA).

Knowledge of ICD‑10 and CPT/HCPC coding guidelines and terminology and a bachelor’s degree strongly preferred. Experience coding for different specialties preferred. Strong knowledge of MS Excel and Word highly preferred.

Salary for this position ranges from $55,480 to $105,120, based on location, experience, education, and skill level. Compensation may vary within this range.

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.

Applicants who require accommodation to participate in the job application process may contact elevancehealthj for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.