Clinical Provider Auditor Senior
Elevance Health

Job Info

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Clinical Provider Auditor Senior

Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.

The Clinical Provider Auditor Sr will be responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.

How you will make an impact:

• Examines claims for compliance with relevant billing and processing guidelines and identifies opportunities for fraud and abuse prevention and control.
• Reviews and conducts analysis of claims and medical records prior to payment and uses required systems/tools to accurately document determinations and continue to next step in the claim's lifecycle.
• Research new healthcare related questions as necessary to aid in investigations and stays abreast of current medical coding and billing issues, trends and changes in laws/regulations.
• Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern to determine patterns of billing behavior.
• Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation.
• Trains new associates.
• Develops, designs and implements new or revised methods to improve the operations.

Minimum Requirements:

• Requires a AA/AS and minimum of 6 years medical coding/auditing experience, including minimum of 4 years in fraud, waste abuse experience; or any combination of education and experience, which would provide an equivalent background.
• Requires coding certification (CPC, CCS, CPMA).

Preferred Skills, Capabilities and Experiences:

• Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology.
• Bachelors degree strongly preferred.

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