Clinical Provider Auditor Senior - Payment Integrity SIU

Clinical Provider Auditor II – Payment Integrity SIU Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. 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. Carelon , a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together.   Among us are care providers, engineers, data scientists, and other dedicated professionals determined to recover, eliminate and prevent unnecessary medical-expense spending. The Clinical Provider Auditor Senior will be responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse. How you will make an impact: 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 to determine patterns of billing behavior. Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation. Trains new associates. Develops, designs and implements new or revised methods to improve the operations.

Requires a AA/AS and minimum of 5 years medical coding/auditing experience, including minimum of 4 years in fraud, waste abuse experience; or any combination of education and experience, which would provide an equivalent background. Requires coding certification (CPC, CCS, CPMA).

Prepay review of Medicare and Medicaid experience highly desired. Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology and Bachelor’s degree strongly preferred. Job Level: Non-Management Exempt Workshift: 1st Shift (United States of America) Job Family: FRD > Audit 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.

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 personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our