Clinical Provider Auditor II - Payment Integrity SIU

Clinical Provider Auditor II - 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. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the centerconnecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together.

Among us are care providers, engineers, data scientists, and other dedicated professionals determined to recover, eliminate and prevent unnecessary medical-expense spending.

The Clinical Provider Auditor II is 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 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.

Minimum 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 and Bachelor's degree strongly preferred.

Job Level: Non-Management Exempt

Workshift: 1st Shift (United States of America)

Job Family: FRD > Audit