Clinical Provider Auditor I

Elevance Health

Clinical Provider Auditor I at Elevance Health identifying risks associated with fraud and abuse in claims. Collaborating with internal units and ensuring regulatory compliance in healthcare.

Posted 6/11/2026full-timeDurham • Kentucky, North Carolina, Tennessee • 🇺🇸 United StatesJuniorWebsite

About the role

Key responsibilities & impact

Identifying issues and/or entities that may pose potential risk associated with fraud and abuse
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

Requirements

What you’ll need

Requires a AA/AS and minimum of 1 year related medical coding/auditing experience
Must achieve coding certification (CPC, CCS, CPMA) within one year of starting in this position
Current CPC certification very strongly preferred
Prior auditing experience is a must for this role
Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology strongly preferred
You must have a strong team spirit and a collaborative mentality

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 codingauditingICD-10CPT codingHCPC codingclaims analysisfraud preventionbilling compliancerisk assessmentclaims lifecycle management

Soft Skills

collaborationteam spiritcommunicationproblem-solvinganalytical thinkingattention to detailinterpersonal skillsinvestigative skillsadaptabilitydecision-making

Certifications

CPCCCSCPMA