Claims Auditor Senior

• Performs audits of and may adjudicate complex high dollar claims while maintaining acceptable levels of claims inventory and age.
• Ensures claim payment accuracy by verifying various aspects of the claim including eligibility, system coding and pricing, pre-authorization, and medical necessity.
• Contacts others to obtain any necessary information.
• Completes and maintains detailed documentation of audit which includes decision methodology, system or processing errors, and monetary discrepancies which are used for financial reporting and trending analysis.
• Provides feedback on claims processing errors; identifies quality improvement opportunities and initiates complex system requests related to coding or system issues.
• Refers overpayment opportunities to Recovery Team.
• Serves as a subject matter expert for Policy and Clinical Guidelines.
• Associates at this level serve as a mentor and resource to other audit staff.
• Must possess strong research and problem solving skills.

• HS diploma or GED.
• Minimum of 4 years related experience in a quality audit capacity (preferably in healthcare or insurance sector); or any combination of education and experience which would provide an equivalent background.

• Working knowledge of insurance industry and medical terminology; detailed knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines strongly preferred.
• Ability to acquire and perform progressively more complex skills and tasks in a production environment strongly preferred.
• BA/BS degree or RN preferred.
• Stop loss background, no stop loss claims auditing background experience preferred.

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.

Who We Are

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 business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

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.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

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. Applicants who require accommodation to participate in the job application process may contact View email address on aplitrak.com for assistance. 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