Clinical Provider Auditor II

Elevance Health

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

Posted 9/25/2026full-timeRemote • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical coding and auditing, with a strong focus on fraud and abuse prevention. Proficient in analyzing claims and medical records while ensuring compliance with relevant guidelines and regulations.

Highest-signal resume keywords

Medical Coding CertificationICD-10 KnowledgeCPT/HCPC Coding GuidelinesFraud, Waste, Abuse ExperienceClaims Analysis

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical CodingClaims AuditingCompliance ReviewRisk AssessmentDocumentation Accuracy

Soft Skills

CollaborationTrainingProblem Solving

Tools & Technologies

Claims Processing SystemsDocumentation Tools

Certifications & Qualifications

CPCCCSCPMA

Industry Keywords

Fraud PreventionBilling GuidelinesHealthcare ComplianceMedical Records ReviewLegal/Regulatory Changes

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 healthcare-related questions to aid investigations
Stay current on medical coding and billing issues, trends, and legal/regulatory changes
Collaborate with the Special Investigation Unit and other internal areas
Recommend interventions for loss control and risk avoidance based on investigation outcomes
Assist with training new associates

Requirements

What you’ll need

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 providing an equivalent background
Coding certification (CPC, CCS, CPMA)
Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology
Candidates must reside within a reasonable commuting distance from a posting location unless an accommodation is granted as required by law
Candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided
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-term disability benefits
Long-term disability benefits
401(k) match
Stock purchase plan
Life insurance
Wellness programs
Financial education resources
Virtual full-time work, except for required in-person training sessions