Claims Auditor I, II & Senior

Position Overview

This posting is for three related positions – Claims Auditor I, Claims Auditor II, and Claims Auditor Senior – where associates enjoy a primarily virtual work environment with required in-person training sessions. Candidates are expected to be within reasonable commuting distance unless an accommodation is provided by law. Each role focuses on auditing high-dollar claims, with increasing levels of independence, responsibility, and subject matter expertise. At Elevance Health, you’ll be joining a Fortune 25 company dedicated to making healthcare simpler and improving lives and communities.

Key Responsibilities

• Performs audits of high dollar claims to ensure payment accuracy.
• Verifies claim aspects including eligibility, pre-authorization, and medical necessity.
• Contacts relevant parties to obtain necessary information.
• Completes and maintains detailed documentation of audits, including decision methodology, system or processing errors, and monetary discrepancies for financial reporting and trend analysis.
• Provides feedback on processing errors and identifies quality improvement opportunities, including basic requests related to coding or system issues.
• Refers overpayment opportunities to the Recovery Team.
• For Claims Auditor II: Independently interprets Medical Policy and Clinical Guidelines in addition to all the above responsibilities.
• For Claims Auditor Senior: Acts as a subject matter expert for Policy and Clinical Guidelines, mentors audit staff, and leverages strong research and problem solving skills.

Required Qualifications

• Claims Auditor I: High School diploma or GED with a minimum of 3 years of claims processing experience (or equivalent combination of education and experience).
• Claims Auditor II: High School diploma or GED with a minimum of 5 years of claims processing experience, including at least 1 year in a quality audit role (preferably in healthcare or insurance), or equivalent experience.
• Claims Auditor Senior: High School diploma or GED with a minimum of 4 years of quality audit experience (preferably in healthcare or insurance), or equivalent experience.

Preferred Qualifications

• Stop loss claims experience is highly preferred.
• Working knowledge of the insurance industry and medical terminology, including relevant systems and processing principles, is strongly preferred.
• Ability to acquire and perform progressively more complex skills and tasks in a production environment.
• Strong research and problem solving skills.

Benefits & Perks

• Compensation: Salary ranges are as follows – Claims Auditor I: $21.41 to $38.88/hr, Claims Auditor II: $22.54 to $40.94/hr, and Claims Auditor Senior: $25.69 to $46.64/hr. Actual compensation may vary based on geographic location, experience, education, and skill level.
• Comprehensive benefits package including medical, dental, vision, and short/long term disability.
• Incentive and recognition programs, equity stock purchase plan, and 401(k) with company match.
• Paid Time Off, paid holidays, and merit increases.