Claims Auditor I, II & Senior

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 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 :

Preferred Skills, Capabilities & Experiences :

For candidates working in person or virtually in the below location(s), the salary

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.