Provider Auditor at Elevance Health in grand prairie, Texas

Job Description:

Location: Grande Prairie, TX Or Houston, TX




Hours: Monday - Friday




Travel: Field Based- Travel to provider locations as needed




Position Overview:



A Provider Auditor's responsibility will include overseeing compliance audit processes and ensuring adherence to regulatory requirements across the organization. A Provider Auditor will support business objectives by managing audit plans and conducting thorough evaluations of internal controls. Key tasks involve developing audit strategies, facilitating approvals, implementing audit procedures, and ensuring compliance with industry standards and regulations, all while managing audit-related budgets and achieving set objectives.



How You Will Make an Impact:

• Selects providers to be reviewed based on historical results of other reviews with providers, network management input and dollar volume of provider
  
  


• Schedules review with provider, analyzes data to select claims to be reviewed, conducts review using medical charts, medical notes, itemized bills and provider contracts
  
  


• Conducts exit interview with provider management team by presenting preliminary review results
  
  


• Verifies dollar amount on claim is correct in claims system and writes report of the findings of the review and requests payments for any overpayments
  
  


• Identifies aberrant patterns of billing and detects potential abuse
  
  


• Participates in developing and/or reviewing department policies and procedures
  
  


• Works on task forces and committees
  
  

Required Qualifications:

• Requires a BA/BS degree and a minimum of 2 years' relevant work experience; or any combination of education and experience, which would provide an equivalent background.
  
  

Preferred Qualifications:

• Experience working in Facets, Macess, and ACMP strongly preferred
  
  


• Previous experience in auditing, particularly in the healthcare sector is preferred.
  
  


• Familiarity with healthcare regulations, billing practices, and compliance standards is preferred
  
  


• Knowledge or experience working with Texas LTSS programs preferred
  
  


• Experience working with Microsoft Word, Excel, and SharePoint 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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

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. Apply Now