Clinical Provider Auditor I - Maryland Behavioral Health
$58,527 - $83,800/Yr
Elevance Health - Hanover, MD
posted 2 months ago
Full-time - Entry Level
Hanover, MD
5,001-10,000 employees
Insurance Carriers and Related Activities
About the position
The Clinical Provider Auditor I position at Elevance Health is responsible for supporting Payment Integrity and Behavioral Health by identifying potential risks associated with fraud and abuse in medical claims. This role involves examining claims for compliance, conducting analyses of claims and medical records, and collaborating with internal teams to recommend interventions for loss control and risk avoidance. The position operates in a hybrid model, requiring the candidate to reside within 50 miles of the Hanover, MD location.
Responsibilities
- Examine claims for compliance with relevant billing and processing guidelines.
- Identify opportunities for fraud and abuse prevention and control.
- Review and conduct analysis of claims and medical records prior to payment.
- Use required systems/tools to accurately document determinations in the claims lifecycle.
- Research healthcare-related questions to aid in investigations.
- 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 investigation outcomes.
Requirements
- Requires an AA/AS degree and a minimum of 1 year related medical coding/auditing experience, or equivalent education and experience.
- 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
- 401(k)
- 401(k) matching
- Dental insurance
- Disability insurance
- Employee assistance program
- Employee stock purchase plan
- Health insurance
