Clinical Provider Auditor I - SIU Fraud and Abuse at Elevance Health in Mason, Ohio

Job Description:

Clinical Provider Auditor I - Carelon Payment Integrity




Location: The ideal candidate will live within 50 miles of one of our pulse point locations and will work on a hybrid work model (1-2 days per week in the office).



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 Clinical Provider Auditor I is responsible for identifying issues and/or entities that may pose potential risks associated with fraud and abuse.



How you will make an impact:

• 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 uses required systems/tools to accurately document determinations and continue to the next step in the claims lifecycle.


• 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.

Minimum Requirments:

• Requires an AA/AS and minimum of 1 year related medical coding/auditing experience; or any combination of education and experience, which would provide an equivalent background.


• Must achieve coding certification (CPC, CCS, CPMA) within one year of starting in this position.

Preferred Skills, Qualifications, and Experiences:

• Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology is strongly preferred.


• Coding certificate (CPS, CCS, or CPMA) highly desired.

For candidates working in person or remotely in the below location(s), the salary* range for this specific position is $26.86 to $46.04.


Locations: California; Colorado; District of Columbia (Washington, DC), Maryland, Nevada; New York; Washington State


In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.


* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law. Apply Now