Clinical Provider Auditor II – Payment Integrity

Elevance Health

Clinical Provider Auditor II responsible for identifying fraud and abuse in healthcare claims. Review compliance and collaborate with internal areas to improve processes.

Posted 6/10/2026full-timeNorfolk • Florida, 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).
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 (unless covered by a collective bargaining agreement)
medical, dental, vision, 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 preventionbilling complianceICD-10 codingCPT codingHCPCS codingclaims analysisrisk avoidanceloss control

Soft Skills

collaborationtrainingcommunicationanalytical thinkingproblem-solving

Certifications

CPCCCSCPMA