Elevance Health

Clinical Provider Auditor Senior - Payment Integrity SIU

Elevance Health$75K — $95K *
Healthcare
5 - 7 years of experience
Job Overview by Ladders

Qualifications

  • AA/AS degree required; 5 years medical coding/auditing experience.
  • 4 years minimum experience in fraud, waste, and abuse.
  • Coding certification required (CPC, CCS, CPMA).
  • Knowledge of ICD-10 and CPT/HCPC coding guidelines preferred.
  • Bachelor’s degree preferred.

Responsibilities

  • Examine claims for compliance with billing guidelines; identify fraud and abuse prevention opportunities.
  • Review claims and medical records prior to payment; document findings accurately.
  • Research healthcare-related questions to assist investigations; stay updated on coding and billing trends.
  • Collaborate with the Special Investigation Unit to identify billing behavior patterns.
  • Recommend interventions for loss control and risk avoidance following investigations.
  • Train new associates on auditing processes and best practices.
  • Develop and implement improved operational methods.

Benefits

  • Flexible hybrid work model with 1-2 in-office days per week to enhance collaboration.
  • Opportunity to work in a dynamic and adaptable workplace environment.
  • Engage in impactful work preventing healthcare fraud and abuse.
  • Collaboration with a Special Investigation Unit to address common concerns.
Full Job Description

Anticipated End Date:

2026-07-31

Position Title:

Clinical Provider Auditor Senior - Payment Integrity SIU

Job Description:

Clinical Provider Auditor II – Payment Integrity SIU

Location: 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 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.

Minimum Requirements:

  • 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).

Preferred Experience:

  • 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.


About Elevance Health

Epoch Health represents the next evolution in comprehensive healthcare specifically for men. Our philosophy is a clinical approach designed to help men enhance their quality of life through truly personalized and professional clinical care. At Epoch we stress appropriate health treatments, proactive screenings and lifestyle modifications.

Elevance Health Careers

Join the vibrant team at Elevance Health, a leader in healthcare solutions, where we prioritize innovation, leadership, and the well-being of our communities. At Elevance Health, we offer more than just job opportunities; we provide a pathway to a fulfilling career in a diverse and inclusive environment.

Work You’ll Do

At Elevance Health, you will be part of a team dedicated to reshaping the future of healthcare through outstanding service and cutting-edge technology. Our professionals enjoy a culture of collaboration and respect that supports both personal and professional growth.

Explore Career Opportunities

Whether you're seeking your first internship or a seasoned professional position, Elevance Health offers a range of employment opportunities across various specialties. Our team is growing, and we are hiring individuals who are passionate about making a difference in healthcare. Explore positions that match your skills and interests in our dynamic company.

Innovate and Lead

Join us and contribute to a culture of innovation and continuous improvement. At Elevance Health, you will work alongside industry leaders and have the chance to develop leadership skills that are crucial in today’s fast-paced healthcare environment. Our leadership and diversity training ensure that all team members are equipped to lead, inspire, and thrive.

Develop Your Career

Elevance Health is committed to the professional growth of our employees. With access to comprehensive benefits, career development programs, and networking opportunities, you can expand your skills and advance your career within a supportive and nurturing environment. Our commitment to professional development is reflected in our robust training programs and our focus on promoting from within.

Benefits and Culture

We understand that the well-being of our employees is paramount. Elevance Health offers competitive benefits designed to support the health, financial security, and work-life balance of our team members. Our inclusive culture fosters innovation and is one of our greatest strengths.

Join Our Team

Ready to make a significant impact in healthcare? Search for open job opportunities at Elevance Health that align with your skills and career ambitions. We are looking for curious, creative, and solution-driven team players who are ready to drive change and deliver solutions.

Stay Connected

Keep up to date with the latest in career opportunities and company news by subscribing to our job alert emails. Tailor your subscription to receive updates that align with your career preferences and see what exciting and rewarding opportunities await at Elevance Health.

Apply Now

Start your journey with Elevance Health by exploring our career portal for available job opportunities. Submit your resume, prepare for your interview, and take the first step towards a rewarding career that makes a real difference.

Elevance Health Careers

Empowering your future in healthcare. Join us and be part of a team that is dedicated to improving lives and communities every day.
Learn more about Elevance Health
Size
3,969 employees
Market Cap
$116.9 billion
Industry
Net Income
$4.5 billion
Founded
1944
5 Year Trend
+10.3%
Revenue
$121.8 billion
NASDAQ

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