[Hiring] Clinical Provider Auditor I @Elevance Health

Role Description

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

• 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.

Qualifications

• 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.

Requirements

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

Benefits

• Market-competitive total rewards including merit increases, paid holidays, Paid Time Off, and incentive bonus programs.
• Medical, dental, vision, short and long term disability benefits.
• 401(k) + match, stock purchase plan, life insurance, wellness programs, and financial education resources.