Evolent Health Auditor in Louisville, Kentucky40290

It’s Time For A Change…

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.

Are we growing? Absolutely—56.7% in year-over-year revenue growth in 2016. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016 and 2017, and one of the “50 Great Places to Work” in 2017 by Washingtonian, and our CEO was number one on Glassdoor’s 2015 Highest-Rated CEOs for Small and Medium Companies. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

Candidates must be located in Louisville, KY or willing/able to relocate

What You’ll Be Doing:


  • Perform target claim audits (desk and on-site) as directed; distribute audit reports by the required due date.

  • Conduct investigations, including but not limited to, data analysis, record review, provider office inspections, and field observations.

  • Communicate audit findings internally to the Program Integrity Unit, as well as to DMS, OIG, OAG and other regulatory entities as needed.

  • Serve as an integral attendee and contributor at Program Integrity Unit meetings.

  • Gather and review data in response to inquiries sent to the Program Integrity Unit.

  • Handle Fraud/ Waste/ Abuse hotline calls and e-mails, respond to messages received and track receipt of calls/ e-mails.

  • Assist in development and implementation of Fraud/ Waste/ Abuse policies and procedures.

  • Maintain up-to-date notes, documentation on respective case load in the Investigation Database.

  • Assist in planning, development, and delivery of Fraud/ Waste/ Abuse related educational training for the company and providers.

  • Act as the Program Integrity Unit Liaison to assigned company departments to provide educational information and solicit feedback.

  • Work with subcontractor program integrity unit representatives during on-going investigations.

  • Maintain confidentiality of all sensitive investigative/audit information.

  • Perform other duties and projects as assigned.

The Experience You Need (Required):

  • Bachelor’s degree from a 4 year college/university.

  • Knowledge and understanding of medical records review process.

  • Knowledge of healthcare services coding and claims billing.

  • 3-5 years of experience in the managed care industry.

  • 1-2 years prior healthcare fraud investigations experience

  • Familiarity with federal, state, and local law enforcement process

  • Extensive experience with subject interview process

  • Strong organizational, interpersonal, and communication skills

  • Inquisitive nature

  • Computer literate (MS, Word, Excel, PowerPoint)

  • Strong personal and professional ethics

  • Must be located in Louisville, KY

Finishing Touches (Preferred):

  • 3-5 years of experience in fraud, waste and abuse investigating in a healthcare operation.

  • Certified Coder with either CPC, CCS or CMPA (Certified Professional Coder, Certified Coding Specialist, Certified Professional Medical Auditor)

  • Knowledge of Health Insurance, Managed Care, Benefit Design, Kentucky Revised Statutes, Kentucky Administrative Code and Federal Regulations.

  • Knowledge of corporate investigative practices.

  • Leadership skills to effectively communicate with staff and regulatory representatives.

  • Investigative, decision-making, problem solving, interpersonal and organizational skills.

  • Proficient understanding of medical terminology, human anatomy, medical tests and procedures, and health conditions.

  • Consistent demonstration of accuracy, thoroughness and timeliness in completing work assignments; detail-oriented.

  • Excellent ability to plan, organize and maintain multiple projects and files.

  • Excellent verbal and written communication skills and interpersonal skills.

  • Proficient experience using Outlook, Word, Excel and PowerPoint in a Windows operating system.

  • Ability to adapt to fluctuating situations.

  • Understanding of healthcare industry, claims processing, investigative process development, and auditing a plus

Evolent Health is an Equal Opportunity/Affirmative Action Employer