Easter Seals Jobs

Claims Auditor Lead

This position will work a hybrid model (remote and office), 1-2 times per week. The Ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.

Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending.

The Claims Auditor Lead is responsible for leading the high dollar audit team within Service Operations.

How you will make an impact:

• Responsible for all team training including but not limited to new hires, cross training, new product and system enhancements.

• Conducts audits for new hires and/or any team member learning a new skill. Reviews, interprets and maintains records of quality and productivity for entire team.

• Coaches, mentors and develops associates to ensure processes, guidelines and tools are utilized correctly.

• Utilizes inventory management strategies to monitor priorities and ensure timely turnaround of all claims.

• Responsible for creating, updating and maintaining departmental policy and claims auditor procedure manuals for accuracy.

• Independently analyzes and makes decisions on complex claim audit issues.

• Serves as subject matter expert on policy, workflow and technical questions. Interfaces with all levels of support including but not limited to production support, medical management, provider /vendor contracting and other audit teams.

• Partners with Management on complex claims reviews and resolution.

• Responsible for reviewing and resolving shared mailbox issues.

• Interprets contracts, prepares monthly reports, and attends meetings as subject matter expert when requested.

• Manages projects as assigned and may work across different platforms or lines of business.

• Reviews and responds to external audit requests.

• Performs audit reviews of and may adjudicate complex high dollar claims by completing an end to end audit with final approval authority.

Minimum Requirements:

Requires a HS diploma or GED and a minimum of 6 years related experience in a quality audit capacity (preferably in healthcare or insurance sector); or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

• WGS Claims experience preferred.

• Working knowledge of insurance industry and medical terminology; detailed knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines strongly preferred.

• Understanding member benefits a plus.

• Interpret provider contracts experience a plus.

• Ability to acquire and perform progressively more complex skills and tasks in a production environment strongly preferred.

• BA/BS degree or RN preferred.

For candidates working in person or remotely in the below location, the salary* range for this specific position is $64,416 to $105,408

Locations: California

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 .

• The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

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.