Provider Auditor Lead - Payment Integrity Complex and Clinical Audit

Elevance Health•Indianapolis, IN

1d•Hybrid

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 Provider Auditor Lead - Specialty Pharmacy will lead the professional audit program for a region and manage the work of vendors contracted to perform audits on the company's behalf.

Requirements

Requires a BA/BS degree and a minimum of 5 years of experience in a related field, including provider audit reimbursement, and analytics; project management and leadership experience; or any combination of education and experience which would provide an equivalent background.

Nice To Haves

Minimum of 2 years of claims review experience highly desired.
Experience related to medical coding, including coding certification, nursing licensure, and/or a clinical background, is strongly preferred.

Responsibilities

Leads day-to-day activities of the audit team, creating and managing workflow assignments, establishing priorities, and serving as a resource for training to lower-leveled audit associates.
Operates as the SME (subject matter expert) for a specific line of business as assigned and documents workflow processes.
Collaborates across business lines through the facilitation of meetings.
Manages vendor relationships with contracted vendors.
Investigates potential fraud and over-utilization by performing the most complex medical reviews via prepayment claims review and post payment auditing.
Conducts provider meetings to discuss audit findings and appeals for the most complex audits.
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.