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Clinical Provider Auditor I
Elevance HealthClinical Provider Auditor I responsible for auditing claims for fraud and abuse prevention. The role involves analysis, collaboration, and compliance within the healthcare sector.
About the role
Key responsibilities & impact- identifying issues and/or entities that may pose potential risk associated with fraud and abuse
- 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
Requirements
What you’ll need- Requires a AA/AS and minimum of 1 year related medical coding/auditing experience
- coding certification (CPC, CCS, CPMA) within one year of starting in this position
- Current CPC certification very strongly preferred
- Prior auditing experience is a must for this role
- Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology strongly preferred
- strong team spirit and a collaborative mentality
Benefits
Comp & perks- merit increases
- paid holidays
- Paid Time Off
- incentive bonus programs
- medical
- dental
- vision
- short and long term disability benefits
- 401(k) +match
- stock purchase plan
- life insurance
- wellness programs
- financial education resources
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
medical codingauditingICD-10CPT codingHCPCS codingclaims analysisfraud preventionbilling compliancerisk assessmentdata documentation
Soft Skills
collaborationteam spiritcommunicationproblem-solvinganalytical thinkingattention to detailinterpersonal skillsadaptabilitycritical thinkinginvestigative skills
Certifications
CPCCCSCPMA