Clinical Provider Auditor I - Maryland Behavioral Health

CareBridge • Hanover, MD

89d • $58,051 - $87,076

About The Position

The Clinical Provider Auditor I supports the Payment Integrity line of business at Carelon Payment Integrity, a member of the Elevance Health family of companies. This field-based role enables associates to primarily operate in the field, traveling to client sites or designated locations as their role requires, with occasional office attendance for meetings or training. This approach ensures flexibility, responsiveness to client needs, and direct, hands-on engagement. The Clinical Provider Auditor I is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.

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.

Nice To Haves

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

Responsibilities

• 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.

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Ambulatory Health Care Services
• Education Level: Associate degree
• Number of Employees: 251-500 employees