Clinical Provider Auditor II – Payment Integrity

Elevance Health

Clinical Provider Auditor II focusing on fraud and waste identification in healthcare claims. Collaborating on investigations and providing solutions within Elevance Health's integrated services.

Posted 6/10/2026full-timeAtlanta • Florida, Texas, Virginia, Wisconsin • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & 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 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.
Assists with training of new associates.

Requirements

What you’ll need

Requires a AA/AS and minimum of 3 years medical coding/auditing experience
including minimum of 1 year in fraud, waste abuse experience
or any combination of education and experience, which would provide an equivalent background.
Requires coding certification (CPC, CCS, CPMA).
Preferred Experience: Prepay review of Medicare and Medicaid experience highly desired.
Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology
Bachelor's degree strongly preferred.

Benefits

Comp & perks

merit increases
paid holidays
Paid Time Off
incentive bonus programs
medical benefits
dental benefits
vision benefits
short and long term disability benefits
401(k) +match
stock purchase plan
life insurance
wellness programs
financial education resources

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical codingauditingfraud preventionICD-10 codingCPT codingHCPCS codingclaims analysisbilling compliancerisk avoidanceloss control

Soft Skills

collaborationtrainingcommunicationanalytical thinkingproblem-solving

Certifications

CPCCCSCPMA