Clinical Provider Auditor I
About The Position
Clinical Provider Auditor I Location: We prefer any of the following cities/States: Woodland Hills, CA; Denver, CO; Miami, FL; Tampa, FL; Atlanta, GA; Chicago, IL; Grand Prairie, TX; Seattle, WA. Hybrid 1: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. 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 an 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 will make an impact: Primary duties may include, but are not limited to: 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.
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.
Nice To Haves
- Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology strongly 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
- In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree
Number of Employees
5,001-10,000 employees
