Clinical Provider Auditor Senior JR132552

Elevance Health • Louisville, OH, United States • $200k - $250k / year • 1m ago

Clinical Provider Auditor Senior

Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.

The Clinical Provider Auditor Sr will be responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.

How you will make an impact:

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 claim's lifecycle.
Research 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 to determine patterns of billing behavior.
Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation.
Trains new associates.
Develops, designs and implements new or revised methods to improve the operations.

Minimum Requirements:

Requires an AA/AS and minimum of 6 years medical coding/auditing experience, including minimum of 4 years in fraud, waste abuse experience; or any combination of education and experience, which would provide an equivalent background.
Requires coding certification (CPC, CCS, CPMA).

Preferred Skills, Capabilities and Experiences: