Provider Auditor (certified Medical Coder)

Provider Auditor (Certified Medical Coder)

Provider Auditor - FRD > Audit

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.

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 Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending.

The Provider Auditor conducts on-site reviews of medical charts, medical notes, itemized bills and providers 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.
• Participates in developing and/or reviewing department policies and procedures.
• Works on task forces and committees.

Minimum Requirements:

Requires either a BA/BS degree, medical coding certification and a minimum of 2 years' relevant work experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

• Provider contract experience is preferred.
• Claims experience preferred.

Job Level: Non-Management Exempt

Workshift:

Job Family: FRD > Audit

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

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. 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.