Clinical Provider Auditor Senior - Payment Integrity SIU

Clinical Provider Auditor II – Payment Integrity SIU Location: This role requires associates to be in-office 1–2 days per week, fostering collaboration and connectivity while providing flexibility to support productivity and work-life balance. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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 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 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 a AA/AS and minimum of 5 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 Experience: Prepay review of Medicare and Medicaid experience highly desired. Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology and Bachelor’s degree strongly preferred. 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 View email address on click.appcast.io for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. #J-18808-Ljbffr Elevance Health