Clinical Provider Auditor II - Payment Integrity SIU

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. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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, and for assessing claims for compliance with billing and processing guidelines. 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 documents determinations accurately in the required systems/tools. 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 AA/AS degree and a minimum of 3 years of medical coding/auditing experience, including at least 1 year in fraud, waste, or abuse; or an equivalent combination of education and experience. Required coding certification (CPC, CCS, or CPMA). Preferred Experience Prepay review of Medicare and Medicaid experience. Knowledge of ICD‑10 and CPT/HCPC coding guidelines and terminology. Bachelor’s degree strongly preferred. Job Level: Non‑Management Exempt Workshift: 1st Shift (United States of America) Job Family: FRD > Audit 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. #J-18808-Ljbffr The Elevance Health Companies, Inc.