Clinical Provider Auditor I

Elevance Health; Columbus (GA); Hybrid; USD 58,051 - 95,369; Full time

Benefits offered by this job

Comprehensive benefits package

Incentive and recognition programs

Equity stock purchase

401k contribution

Job summary

An established industry player is seeking a Clinical Provider Auditor I to enhance payment integrity and behavioral health. This role involves examining claims for compliance, conducting thorough analyses of medical records, and collaborating with internal teams to mitigate risks associated with fraud and abuse. The ideal candidate will have a strong background in medical coding and auditing, with a commitment to achieving coding certification shortly after starting. Join a forward-thinking company that offers a hybrid work model and a comprehensive benefits package, making this an exciting opportunity for those passionate about healthcare integrity.

Qualifications

• 1+ years of related medical coding/auditing experience required.
• Coding certification (CPC, CCS, CPMA) must be achieved within 6 months.

Responsibilities

• Examine claims for compliance and identify fraud opportunities.
• Conduct analysis of claims and medical records prior to payment.
• Collaborate with the Special Investigation Unit on investigations.

Skills

Medical Coding

Fraud Prevention

Claims Analysis

Regulatory Compliance

Education

AA/AS Degree

Tools

Claims Processing Systems

Job description

Clinical Provider Auditor I

Supports Payment Integrity & Behavioral Health

Location: Alternate locations may be considered. This position will work in a hybrid model (remote and office). 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 Clinical Provider Auditor I is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.

How will you 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 claims lifecycle.
• Researches 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.
• Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation.

Minimum Requirements

• Requires a AA/AS and minimum of 1 year related medical coding/auditing experience; or any combination of education and experience, which would provide an equivalent background.
• Must achieve coding certification (CPC, CCS, CPMA) within 6 months of starting in this position.

Preferred Skills, Capabilities and Experiences

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

For candidates working in person or remotely in the below locations, the salary range for this specific position is $58,051 to $95,369.

Locations: District of Columbia (Washington, DC); Illinois and Maryland.

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).

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.