Claims Auditor I
Claims Auditor I
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Job Description
Anticipated End Date:
Position Title:
Claims Auditor IJob Description:
Claims Auditor I
Virtual: 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.
How you will make an impact:
Performs audits of and may adjudicate high dollar claims while maintaining acceptable levels of claims inventory and age.
Ensures claim payment accuracy by verifying various aspects of the claim including eligibility system coding and pricing pre-authorization and medical necessity.
Contacts others to obtain any necessary information.
Gather necessary information by contacting relevant parties for large dollar validation and stop loss submission.
Maintain meticulous documentation of audits and stop loss submission including decision methodology system or processing errors and monetary discrepancies.
Provide feedback on processing errors and highlight quality improvement opportunities.
Initiate requests related to large claim trends or system issues where applicable.
Manage large claim stop loss carrier requirements and requests.
Minimum Requirements
- 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.
Preferred Skills Capabilities and Experiences:
- 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.
Job Level:
Non-Management Non-ExemptWorkshift:
1st Shift (United States of America)Job Family:
CLM > Claims SupportPlease 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.
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 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.
Employment Type
Full-Time
