Clinical Provider Auditor II (Payment Integrity SIU)

Location: Virtual full-time work with required in-person training; candidates must reside within a reasonable commuting distance of an hirify.global office in Norfolk or Ashburn, Virginia; Tampa, Florida; Atlanta or Grand Prairie, Georgia/Texas; or Waukesha, Wisconsin.

Salary: $58,400–$107,740 annually for candidates working in Virginia.

Company

Carelon, part of hirify.global, provides healthcare services focused on integrated, personalized, and affordable care.

What you will do

• Examine claims for compliance with billing and processing guidelines.
• Analyze claims and medical records before payment and document determinations in required systems.
• Identify potential fraud, waste, and abuse risks and support prevention and control activities.
• Research healthcare questions, medical coding developments, trends, and regulatory changes.
• Collaborate with the Special Investigation Unit and internal stakeholders.
• Recommend loss-control and risk-avoidance interventions and assist with training new associates.

Requirements

• Associate degree in arts or science and at least three years of medical coding or auditing experience, including at least one year of fraud, waste, and abuse experience, or an equivalent combination of education and experience.
• Required coding certification: CPC, CCS, or CPMA.
• Knowledge of ICD-10 and CPT/HCPCS coding guidelines and terminology.
• Ability to attend required in-person training and reside within a reasonable commuting distance of a listed office location.

Nice to have

• Prepayment review experience with Medicare and Medicaid.
• Bachelor’s degree.

Culture & Benefits

• Virtual work model designed to support flexibility, productivity, and work-life integration.
• Comprehensive benefits package with medical, dental, vision, disability, and life insurance.
• Paid holidays, paid time off, incentive programs, wellness programs, and financial education resources.
• 401(k) with company match and stock purchase plan.