Quality Auditor, Hospital Bill Audits & Itemized Bill Review (Program Integrity)

Position Overview The Quality Auditor provides quality oversight of hospital bill audits and itemized bill reviews. This role validates the accuracy, supportability, and defensibility of audit findings (pre‑ and/or post‑payment), ensuring alignment with documentation standards, payer policy, and contractual reimbursement requirements. The Quality Auditor identifies opportunities to improve audit performance, reduce overturns, and strengthen audit workflows through structured quality monitoring, feedback, and trend reporting. Responsibilities Perform retrospective quality audits (QA) of audit cases involving inpatient and outpatient facility claims, including itemized bill line validation and supporting documentation review. Validate that findings are supported, accurately documented, and consistent with audit rationale. Ensure audit determinations appropriately apply payer policies, coding/billing guidelines, and reimbursement rules (e.g., UB‑04/revenue codes, HCPCS/CPT, modifiers, units, bundling/packaging logic, duplicates, late charges, and non‑covered items). Confirm the audit file contains complete evidence to support recoveries/avoidance and to withstand provider appeals. Apply established QA methodology to evaluate performance consistently. Identify and classify errors (clinical, billing/technical, documentation, policy application, calculation/reimbursement, communication) and track severity and financial impact. Maintain quality dashboards and trending reports (accuracy rate, overturn predictors, top error drivers, rework rates, timeliness, and recurring provider billing issues). Participate in calibration sessions with reviewers to ensure consistent interpretation of billing criteria and policy standards. Provide structured feedback to audit teams, including coaching, pattern identification, and recommendations for corrective action plans (CAPs). Support business reviews by summarizing quality findings, root causes, and improvement opportunities. Recommend updates to job aids, templates, and audit checklists to reduce variation and improve defensibility. Escalate high‑risk issues (e.g., suspected fraud indicators, repeated noncompliance with requirements, or systemic quality breakdowns) to leadership. Required Qualifications BA/BS degree in a related field. Minimum of 7 years reimbursement experience, including performing detailed financial modeling and economic analyses. Alternatively, an equivalent combination of education and experience. Preferred Qualifications Registered Nurse (RN) license. Certifications (any relevant): CCS, CPC. Clinical experience (e.g., acute care, med‑surg, ICU, ED, OR, case management, utilization review). Experience in payment integrity, clinical auditing, or hospital bill audit support. Strong ability to interpret medical records and connect documentation to billed services and audit determinations. Working knowledge of hospital billing concepts (UB‑04, revenue codes, itemized bills) and how clinical documentation supports charges and units. Knowledge of common payment policies and guidelines (CMS‑based rules as applicable, MCO policies, and/or commercial payer policies). Familiarity with hospital coding/reimbursement concepts (DRG/APC, chargemaster, NCCI, OPPS/IPPS principles). Experience with audit platforms/claims systems (payer or vendor tools). Location & Work Hours Location: Norfolk VA, Mason OH, Indianapolis IN, Louisville KY, Atlanta GA, Miami FL, Grand Prairie TX, Overland Park KS. Hours: Standard working hours. Travel: 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. Benefits 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) with match. Stock purchase plan, life insurance, wellness programs, and financial education resources. 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.