Clinical Provider Auditor II
About The Position
The Clinical Provider Auditor II is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse. This role examines claims for compliance with relevant billing and processing guidelines and identifies opportunities for fraud and abuse prevention and control. The auditor reviews and conducts analysis of claims and medical records prior to payment, using required systems/tools to accurately document determinations. They research new healthcare-related questions as necessary to aid in investigations and stay abreast of current medical coding and billing issues, trends, and changes in laws/regulations. The position 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 investigation outcomes, and assists with training of new associates.
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
- Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology.
- Bachelors 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
