Elevance Health Clinical Provider Auditor Senior St. Louis, Missouri Apply Now
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 the 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 operations.
Minimum Requirements:
Requires an AA/AS and a minimum of 6 years medical coding/auditing experience, including a 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:
Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state, and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
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