Clinical Provider Auditor I

Elevance Health•Mason, OH

3d•Remote

About The Position

The Clinical Provider Auditor I identifies issues and entities that may pose potential risk associated with fraud and abuse. The role examines claims for compliance with billing and processing guidelines, reviews claims and medical records before payment, and documents determinations in required systems and tools. It also researches healthcare-related questions to support investigations, keeps current on medical coding and billing issues and regulatory changes, collaborates with the Special Investigation Unit and other internal teams, and recommends interventions to control losses and avoid risk.

Requirements

Associate of Arts or Associate of Science degree and at least 1 year of related medical coding or auditing experience, or an equivalent combination of education and experience.
Must achieve a coding certification (CPC, CCS, or CPMA) within one year of starting in the position.

Nice To Haves

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

Responsibilities

Examine claims for compliance with relevant billing and processing guidelines and identify opportunities for fraud and abuse prevention and control.
Review and analyze claims and medical records prior to payment.
Use required systems and tools to accurately document determinations and advance cases to the next step in the claims lifecycle.
Research healthcare-related questions as needed to support investigations.
Stay abreast of current medical coding and billing issues, trends, and changes in laws and regulations.
Collaborate with the Special Investigation Unit and other internal areas on matters of mutual concern.
Recommend possible interventions for loss control and risk avoidance based on investigation outcomes.