Clinical Provider Auditor II - Payment Integrity SIU
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. Among us are care providers, engineers, data scientists, and other dedicated professionals determined to recover, eliminate and prevent unnecessary medical-expense spending. The Clinical Provider Auditor II 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 3 years medical coding/auditing experience, including minimum of 1 year in fraud, waste abuse experience; or any combination of education and experience, which would provide an equivalent background.
- Requires coding certification (CPC, CCS, CPMA).
Nice To Haves
- Prepay review of Medicare and Medicaid experience highly desired.
- Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology and Bachelor’s degree 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.
- Assists with training of new associates.
Benefits
- merit increases
- paid holidays
- Paid Time Off
- incentive bonus programs
- medical
- dental
- vision
- short and long term disability benefits
- 401(k) +match
- stock purchase plan
- life insurance
- wellness programs
- financial education resources
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
