Clinical Provider Auditor II

Summary

Elevance Health is a healthcare company focused on improving lives and simplifying healthcare. The Clinical Provider Auditor II examines claims and medical records for billing compliance, investigates potential fraud and abuse, recommends loss-control interventions, and supports associate training.

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

Skills

• 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)
• Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology

Qualifications

Must Haves

• 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

Benefits

• The role enables associates to work virtually full-time, except for required in-person training sessions.
• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution
• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs
• Medical benefits
• Dental benefits
• Vision benefits
• Short-term disability benefits
• Long-term disability benefits
• 401(k) + match
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources