Provider Auditor Senior - Payment Integrity Complex and Clinical Audit

Provider Auditor Senior – Payment Integrity Complex and Clinical Audit 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. 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. Carelon , a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are care providers, engineers, data scientists, and other dedicated professionals determined to recover, eliminate and prevent unnecessary medical-expense spending. 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.

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.

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