Anticipated End Date:2026-09-18
Position Title:Provider Auditor Senior - Payment Integrity Complex and Clinical Audit
Job Description:Provider Auditor Senior - Payment Integrity Complex and Clinical AuditLocation: 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
Provider Auditor Senior will be responsible for conducting on-site reviews of medical charts, medical notes, itemized bills and provider contracts to ensure that a claim is paid in accordance with the contract, provider reimbursement policies, and industry standards.
How you will make an impact:- Selects providers to be reviewed based on historical results of other reviews with providers, network management input and dollar volume of provider.
- Schedules review with provider, analyzes data to select claims to be reviewed, conducts review using medical charts, medical notes, itemized bills and provider contracts.
- Conducts exit interview with provider management team by presenting preliminary review results.
- Verifies dollar amount on claim is correct in claims system and writes report of the findings of the review and requests payments for any overpayments.
- Identifies aberrant patterns of billing and detects potential abuse.
- Mentors and trains Provider Auditor as needed.
- Drafts department policies and procedures and other educational materials.
- Works on task forces and committees representing functional area.
Minimum Requirements:- Requires a BA/BS degree and a minimum of 3 years equivalent work experience; or any combination of education and experience, which would provide an equivalent background.
Preferred Skills, Capabilities and Experiences:- RN and medical coding certification strongly preferred.
- Experience with billing/auding for Home Infusion, DME and/or Dialysis preferred.
- Managed care experience (health plan/payor environment) with understanding of medical coding.
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.
NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words - the job is posted until 3/13, not through 3/13.
