Clinical Provider Auditor I

Elevance Health

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

Posted 10/13/2026full-timeUnited StatesJuniorWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in medical coding and auditing, with a strong understanding of ICD-10 and CPT/HCPC coding guidelines. Capable of identifying fraud and abuse risks while collaborating effectively with internal teams to recommend loss control interventions.

Highest-signal resume keywords

Medical Coding Certification (CPC, CCS, CPMA)ICD-10 Coding GuidelinesCPT/HCPC Coding GuidelinesClaims Auditing ExperienceBehavioral Health Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical CodingClaims ReviewFraud PreventionCompliance AnalysisRisk Assessment

Soft Skills

CollaborationAnalytical ThinkingProblem Solving

Tools & Technologies

Claims Processing SystemsDocumentation Tools

Certifications & Qualifications

CPCCCSCPMA

Industry Keywords

Fraud and Abuse PreventionBilling GuidelinesHealthcare RegulationsMedical Records AnalysisLoss Control

About the role

Key responsibilities & impact

Identify issues and/or entities that may pose potential risk associated with fraud and abuse
Examine claims for compliance with relevant billing and processing guidelines
Identify opportunities for fraud and abuse prevention and control
Review and analyze claims and medical records prior to payment
Use required systems/tools to accurately document determinations and continue to the next step in the claims lifecycle
Research new healthcare-related questions to aid investigations
Stay current on medical coding and billing issues, trends, and changes in laws/regulations
Collaborate with the Special Investigation Unit and other internal areas on matters of mutual concern
Recommend interventions for loss control and risk avoidance based on investigation outcomes

Requirements

What you’ll need

Requires a AA/AS
Minimum of 1 year related medical coding/auditing experience
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
Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology strongly preferred
Experience in Behavioral Health preferred
Candidates must reside within a reasonable commuting distance from the posting location(s), unless accommodation is granted as required by law
Certain patient/member-facing roles require COVID-19 and Influenza vaccination unless an acceptable explanation is provided

Benefits

Comp & perks

Merit increases
Paid holidays
Paid Time Off
Incentive bonus programs
Medical benefits
Dental benefits
Vision benefits
Short-term disability benefits
Long-term disability benefits
401(k) + match
Stock purchase plan
Life insurance
Wellness programs
Financial education resources
Virtual full-time work arrangement, except for required in-person training sessions
Professional growth opportunities
COVID-19 vaccination coverage/requirement for certain patient/member-facing roles