Clinical Provider Auditor II

About the position 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; Richmond, VA 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. How you will make an impact: 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. Assists with training of new associates. Minimum Requirements: Requires a AA/AS and minimum of 3 years medical coding/auditing experience, including minimum of 1 year in fraud, waste abuse experience; or any combination of education and experience, which would provide an equivalent background. Requires coding certification (CPC, CCS, CPMA). Preferred Skills, Capabilities and Experiences: Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology. Bachelors degree strongly preferred. Experience coding for different specialties preferred. Strong knowledge of MS Excel and Word highly preferred. For candidates working in person or virtually in the below locations, the salary range for this specific position is $55,480 to $105,120 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. Responsibilities • 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. • Assists with training of new associates. Requirements • Requires a AA/AS and minimum of 3 years medical coding/auditing experience, including minimum of 1 year in fraud, waste abuse experience; or any combination of education and experience, which would provide an equivalent background. • Requires coding certification (CPC, CCS, CPMA). Nice-to-haves • Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology. • Bachelors degree strongly preferred. • Experience coding for different specialties preferred. • Strong knowledge of MS Excel and Word highly preferred. Benefits • comprehensive benefits package • incentive and recognition programs • equity stock purchase • 401k contribution Apply tot his job Apply To this Job