Environmental Compliance Auditor
AECOM
Clinical Provider Auditor II
Elevance Health
full-time
Posted on:
Location: Missouri, Virginia, Wisconsin • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Identifies issues/entities that may pose potential risk associated with fraud and abuse.\n
- Examines claims for compliance with relevant billing and processing guidelines and identifies opportunities for fraud and abuse prevention and control.\n
- 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.\n
- 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.\n
- Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern.\n
- Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation.\n
- Assists with training of new associates.
Requirements
- AA/AS degree\n
- minimum of 3 years medical coding/auditing experience, including minimum of 1 year in fraud, waste abuse experience\n
- any combination of education and experience, which would provide an equivalent background\n
- coding certification (CPC, CCS, CPMA)
