Job Overview
Compensation
Salary
Range $76,608.00 - $95,760.00
Benefits
Health Insurance
Dental Insurance
Vision Insurance
short term disability
long term disability
401k Match
Paid Time Off
Job Description
Carelon, a proud member of the Elevance Health family of companies, is a leading healthcare services organization dedicated to transforming whole-health care. By taking a whole-health approach, Carelon integrates physical, behavioral, social, and pharmacy services along with clinical expertise, cutting-edge research, operations, and advanced technology. This comprehensive care model fosters more integrated, personalized, and affordable healthcare solutions that are designed to improve outcomes for individuals and communities alike. Among the diverse team are specialty-care physicians, nurse practitioners, pharmacists, engineers, data scientists, and other health professionals who are united by a shared mission: to make a positive impact on whole health.
Carelon Behavioral Health, a part of Elevance Health, leverages extensive experience, expertise, compassion, and dedication to address the most pressing challenges in healthcare. Rooted in the legacy of one of the largest healthcare systems in the United States, Carelon Behavioral Health is uniquely positioned to innovate and deliver better care through behavioral health services. This role is crucial in ensuring the integrity and quality of behavioral health and payment processes through expert auditing.
The Clinical Provider Auditor Lead position is a vital role based in Maryland, ideally near Hanover, MD Pulse Point, responsible for leading a professional audit program supporting Payment Integrity and Behavioral Health services. This field-based role primarily operates in the field, requiring travel to client sites or designated locations, with occasional office attendance for meetings and training. Candidates must reside within Maryland and be within reasonable commuting distance to fulfill hybrid work policy requirements.
In this leadership role, the Clinical Provider Auditor Lead oversees day-to-day audit activities at a regional level, managing vendor relationships and the contracted vendors performing audit services. Responsibilities include resource allocation, prioritizing audit tasks, ensuring compliance with contractual terms, collaborating directly with providers to discuss audit results, negotiating settlements, and adjusting claims based on audit findings. The auditor lead also supports larger organizational reimbursement and audit initiatives and contributes to the development of educational materials for internal staff and providers. This role requires a blend of clinical knowledge, auditing expertise, leadership skills, and a strong foundation in medical and behavioral health coding practices.
The position requires a minimum of a bachelor’s degree and at least five years of related experience in provider audit or reimbursement-related fields, or equivalent combinations of education and experience. Preferred qualifications include medical coding certification (such as CPC, CCS, or CPMA), clinical background, project management, leadership experience, and behavioral health coding and auditing expertise.
This full-time position offers a competitive salary range of $76,608 to $95,760, plus a comprehensive benefits package from Elevance Health. Benefits include health insurance, dental and vision coverage, disability benefits, retirement contributions, stock purchase plans, paid time off, and wellness programs. Elevance Health prioritizes equitable pay and inclusive hiring practices and requires COVID-19 and influenza vaccinations for candidates in patient-facing roles.
Joining Carelon and Elevance Health means becoming part of a Fortune 25 company dedicated to improving lives and communities by making healthcare simpler and more efficient. The company encourages professional growth and offers a culture rooted in shared values and behaviors that drive mutual success for consumers, associates, communities, and the business. Elevance Health is committed to equal employment opportunities and accommodations to ensure a diverse and supportive workplace environment.
Carelon Behavioral Health, a part of Elevance Health, leverages extensive experience, expertise, compassion, and dedication to address the most pressing challenges in healthcare. Rooted in the legacy of one of the largest healthcare systems in the United States, Carelon Behavioral Health is uniquely positioned to innovate and deliver better care through behavioral health services. This role is crucial in ensuring the integrity and quality of behavioral health and payment processes through expert auditing.
The Clinical Provider Auditor Lead position is a vital role based in Maryland, ideally near Hanover, MD Pulse Point, responsible for leading a professional audit program supporting Payment Integrity and Behavioral Health services. This field-based role primarily operates in the field, requiring travel to client sites or designated locations, with occasional office attendance for meetings and training. Candidates must reside within Maryland and be within reasonable commuting distance to fulfill hybrid work policy requirements.
In this leadership role, the Clinical Provider Auditor Lead oversees day-to-day audit activities at a regional level, managing vendor relationships and the contracted vendors performing audit services. Responsibilities include resource allocation, prioritizing audit tasks, ensuring compliance with contractual terms, collaborating directly with providers to discuss audit results, negotiating settlements, and adjusting claims based on audit findings. The auditor lead also supports larger organizational reimbursement and audit initiatives and contributes to the development of educational materials for internal staff and providers. This role requires a blend of clinical knowledge, auditing expertise, leadership skills, and a strong foundation in medical and behavioral health coding practices.
The position requires a minimum of a bachelor’s degree and at least five years of related experience in provider audit or reimbursement-related fields, or equivalent combinations of education and experience. Preferred qualifications include medical coding certification (such as CPC, CCS, or CPMA), clinical background, project management, leadership experience, and behavioral health coding and auditing expertise.
This full-time position offers a competitive salary range of $76,608 to $95,760, plus a comprehensive benefits package from Elevance Health. Benefits include health insurance, dental and vision coverage, disability benefits, retirement contributions, stock purchase plans, paid time off, and wellness programs. Elevance Health prioritizes equitable pay and inclusive hiring practices and requires COVID-19 and influenza vaccinations for candidates in patient-facing roles.
Joining Carelon and Elevance Health means becoming part of a Fortune 25 company dedicated to improving lives and communities by making healthcare simpler and more efficient. The company encourages professional growth and offers a culture rooted in shared values and behaviors that drive mutual success for consumers, associates, communities, and the business. Elevance Health is committed to equal employment opportunities and accommodations to ensure a diverse and supportive workplace environment.
Job Requirements
- Requires a BA/BS and minimum of 5 years experience in a related field which could include provider audit reimbursement or any combination of education and experience which would provide an equivalent background
- candidate must reside within the state of Maryland and be within reasonable commuting distance to Hanover MD Pulse Point
- ability to travel to client sites or designated locations as required
- compliance with company policies including COVID-19 and influenza vaccination requirements for patient-facing roles
Job Qualifications
- Requires a BA/BS
- minimum of 5 years experience in a related field such as provider audit or reimbursement
- experience related to medical coding including coding certification and a clinical background strongly preferred
- project management experience strongly preferred
- leadership experience strongly preferred
- behavioral health coding and auditing experience preferred
- coding certification such as CPC CCS or CPMA preferred
Job Duties
- Leads day-to-day activities of the audit team providing allocation of resources establishing priorities and serving as resource to lower-leveled audit associates
- manages vendor relationships with contracted vendors
- periodically audits work of vendors and ensures that terms of contract are being satisfied
- conducts provider meetings to discuss audit findings and appeals for most complex audits
- negotiates settlements
- researches claims payment methodologies and fee schedule pricing of claims
- adjusts and re-prices claims per audit findings
- assists in resolving contractual issues with providers and in reviewing audit process policy and procedures
- prepares and analyzes various reports to demonstrate recoveries and potential issues with providers
- assists manager with reimbursement/audit initiatives as identified
- supports enterprise initiatives and develops educational materials for internal staff and providers
Job Criteria
Experience
Mid Level (3-7 years)
Job Location
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