Clinical Provider Auditor I - Maryland Behavioral Health

$58,527 - $83,800/Yr

Elevance Health

Full-time - Entry Level

11-50 employees

Insurance Carriers and Related Activities

About the position

The Clinical Provider Auditor I position at Elevance Health focuses on supporting Payment Integrity and Behavioral Health by identifying potential risks associated with fraud and abuse in medical claims. The role involves examining claims for compliance, conducting analyses, and collaborating with internal teams to recommend interventions for loss control and risk avoidance.

Responsibilities

• Examine claims for compliance with relevant billing and processing guidelines and identify opportunities for fraud and abuse prevention and control.
• Review and conduct analysis of claims and medical records prior to payment, using required systems/tools to accurately document determinations.
• Research new healthcare-related questions as necessary to aid in investigations and stay abreast of current medical coding and billing issues, trends, and changes in laws/regulations.
• Collaborate with the Special Investigation Unit and other internal areas on matters of mutual concern.
• Recommend possible interventions for loss control and risk avoidance based on the outcome of the investigation.

Requirements

• Requires a AA/AS and minimum of 1 year related medical coding/auditing experience; or any combination of education and experience that would provide an equivalent background.
• Must achieve coding certification (CPC, CCS, CPMA) within 6 months of starting in this position.

Nice-to-haves

• Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology strongly preferred.
• Behavioral Health coding and auditing experience preferred.

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution