Clinical Provider Auditor I

Elevance Health (Anthem); Mason (OH); Ibrido; USD 55.000 - 70.000; Tempo pieno

Vantaggi offerti da questo lavoro

Merit increases

Paid holidays

Paid Time Off

Medical

Dental

Vision

Disability insurance

401(k) +match

Stock purchase plan

Life insurance

Wellness programs

Descrizione del lavoro

Elevance Health seeks a Clinical Provider Auditor I to identify fraud and abuse risks in claims and medical records. The role emphasizes thorough documentation and collaboration with the Special Investigation Unit in a hybrid work model.

Responsibilities include examining claims for billing compliance, researching coding issues, and recommending interventions to control losses. A minimum AA/AS and 1 year of related experience are required, with certification within the first year.

Competenze

• AA/AS and minimum 1 year related medical coding/auditing experience required.
• Must achieve coding certification (CPC, CCS, CPMA) within 1 year of starting.
• Knowledge of ICD-10 and CPT/HCPCS preferred.

Mansioni

• Examines claims for compliance with billing guidelines and identifies fraud risk.
• Reviews claims and medical records prior to payment and documents determinations.
• Researches healthcare questions to aid investigations and stays updated on coding issues.
• Collaborates with Special Investigation Unit and other internal areas.
• Recommends interventions for loss control based on investigations.

Conoscenze

Medical coding

Auditing

Documentation

Attention to detail

Formazione

AA/AS degree

Descrizione del lavoro

Clinical Provider Auditor I

Location

This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

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

How you'll make a difference

• 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 one year of starting in this position.

Preferred skills, qualifications and experiences

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

#LI

Job Level: Non-Management Non-Exempt

Job Family: FRD > Audit

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.

Benefits

• merit increases
• paid holidays
• Paid Time Off
• 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
• 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.

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 should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. Qualified applicants with