Clinical Provider Auditor Lead - Maryland Behavioral Health

Elevance Health•Hanover, MD

1d•$76,608 - $95,760•Hybrid

About The Position

Clinical Provider Auditor Lead Supports Payment Integrity & Behavioral Health. 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 specialty-care physicians, nurse practitioners, pharmacists, engineers, data scientists, and other dedicated and caring health professionals. While our roles may differ, our purpose is shared: to make a positive impact on whole health. A proud member of the Elevance Health family of companies, Carelon Behavioral Health uses our powerful combination of experience, expertise, dedication and compassion to see what's possible and what's better. Born out of one of the largest healthcare systems organization in the United States, our rich history gives us a unique and valuable perspective on how to solve the most pressing healthcare challenges. 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. The Clinical Provider Auditor Lead is responsible for leading the professional audit program for a region and manages the work of vendors contracted to perform audits on the company's behalf.

Requirements

Requires a BA/BS and minimum of 5 years experience in a related field, which could include provider audit, reimbursement; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

Experience related to medical coding, including coding certification and a clinical background, project management and leadership experience strongly preferred.
Behavioral Health coding and auditing experience preferred.
Coding certification (CPC, CCS, CPMA) preferred.

Responsibilities

Leads day-to-day activities of the audit team, providing allocation of resources, establishing priorities, and serving as resource to lower-leveled audit associates.
Manages vendor relationships with contracted vendors.
Periodically audits work of vendors and ensures that terms of contract are being satisfied.
Conducts provider meetings to discuss audit findings and appeals for most complex audits.
Negotiates settlements.
Researches claims payment methodologies and fee schedule pricing of claims.
Adjusts and re-prices claims per audit findings.
Assists in resolving contractual issues with providers and in reviewing audit process, policy and procedures.
Prepares and analyzes various reports to demonstrate recoveries and potential issues with providers.
Assists manager with reimbursement/audit initiatives as identified.
Supports enterprise initiatives and develops educational materials for internal staff and providers.