Job Information
Elevance Health Clinical Provider Auditor II in INDIANAPOLIS, Indiana
Clinical Provider Auditor II
Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.
Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is 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 claim's lifecycle.
Research 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 an AA/AS and minimum of 4 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 Skills, Capabilities and Experiences:
- Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology and bachelor's degree strongly preferred.