Provider Auditor Lead - Payment Integrity Complex & 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 Lead - Specialty Pharmacy will lead the professional audit program for a region and manage the work of vendors contracted to perform audits on the company's behalf.
How you will make an impact:
Leads day-to-day activities of the audit team, creating and managing workflow assignments, establishing priorities, and serving as a resource for training to lower-leveled audit associates.
Operates as the SME (subject matter expert) for a specific line of business as assigned and documents workflow processes.
Collaborates across business lines through the facilitation of meetings.
Manages vendor relationships with contracted vendors.
Investigates potential fraud and over-utilization by performing the most complex medical reviews via prepayment claims review and post payment auditing.
Conducts provider meetings to discuss audit findings and appeals for the most complex audits.
Researches claims payment methodologies and fee schedule pricing of claims.
Adjusts and re-prices claims per audit findings.
Assists in resolving contractual issues with providers and in reviewing audit process policy and procedures.
Prepares and analyzes various reports to demonstrate recoveries and potential issues with providers.
Assists manager with reimbursement/audit initiatives as identified.
Supports enterprise initiatives and develops educational materials for internal staff and providers.
Minimum Requirements:
Requires a BA/BS degree and a minimum of 5 years of experience in a related field, including provider audit reimbursement, and analytics; project management and leadership experience; or any combination of education and experience which would provide an equivalent background.
Preferred Skills, Capabilities and Experiences:
Minimum of 2 years of claims review experience highly desired.
Experience related to medical coding, including coding certification, nursing licensure, and/or a clinical background, is strongly preferred.
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.
Who We Are
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 our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and 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 and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration (https://info.flclearinghouse.com/) .
