Clinical Provider Auditor II - Payment Integrity

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. Requirements 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). Preferred Experience: Prepay review of Medicare and Medicaid experience highly desired. Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology Bachelor's degree strongly preferred. #J-18808-Ljbffr Jobtailor