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Claims Auditor I, II
1 month ago
Claims Auditor I, II, and Senior This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. 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. The Claims Auditor I is responsible for pre and post payment and adjudication audits of high dollar claims for limited lines of business, claim types and products including specialized claims with appropriate guidance from management and peers. The Claims Auditor II is responsible for audits of high dollar claims across the stop loss business, including specialized claims, working independently and without significant guidance. The Claims Auditor Senior is responsible for auditing of high dollar claims across the stop loss business, including complex specialized claims within Service Experience. Serves as the subject matter expert for the unit. How you will make an impact: Performs audits of high dollar claims. Ensures claim payment accuracy by verifying various aspects of the claim including eligibility, pre-authorization, and medical necessity. Contacts others to obtain any necessary information. Completes and maintains detailed documentation of the audit which includes decision methodology, system or processing errors, and monetary discrepancies which are used for financial reporting and trending analysis. Provides feedback on processing errors; identifies quality improvement opportunities and initiates basic requests related to coding or system issues, where applicable. Refers overpayment opportunities to Recovery Team. Claims Auditor II - all the above, plus: Independently interprets Medical Policy and Clinical Guidelines. Claims Auditor Senior - all the above, plus: Serves as a subject matter expert for Policy and Clinical Guidelines. Associates at this level serve as a mentor and resource to other audit staff. Must possess strong research and problem solving skills. Minimum Requirements: Claims Auditor I: Requires a HS diploma or GED and a minimum of 3 years of claims processing experience; or any combination of education and experience which would provide an equivalent background. Claims Auditor II: Requires a HS diploma or GED and a minimum of 5 years of claims processing experience including a minimum of 1 year related experience in a quality audit capacity (preferably in healthcare or insurance sector); or any combination of education and experience which would provide an equivalent background. Claims Auditor Senior: Requires a HS diploma or GED and a minimum of 4 years related experience in a quality audit capacity (preferably in healthcare or insurance sector); or any combination of education and experience which would provide an equivalent background. Preferred Skills, Capabilities & Experiences: Stop loss claims experience highly preferred. Working knowledge of insurance industry and medical terminology; working knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines strongly preferred. Ability to acquire and perform progressively more complex skills and tasks in a production environment strongly preferred. Strong research and problem solving skills preferred. For candidates working in person or virtually in the below location(s), the salary range for this specific position is: Claims Auditor I $21.41 to $38.88/hr Claims Auditor II $22.54 to $40.94/hr Claims Auditor Senior $25.69 to $46.64/hr Locations: Illinois, Massachusetts, Minnesota, Washington State In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. Who We Are Elevance Health is a health company dedicated to improving lives and communities and making healthcare simpler. 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. 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 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.
