Clinical Provider Auditor I - Maryland Behavioral Health

Elevance Health•Hanover, MD

3d•$29 - $36•Hybrid

About The Position

Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. The Clinical Provider Auditor I will be responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse. 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. Candidates must reside within the state of Maryland and within distance of our Hanover, MD Pulse Point.

Requirements

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.
Must reside within the state of Maryland and within distance of our Hanover, MD Pulse Point.

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.