Clinical Provider Auditor I - SIU Fraud and Abuse

$55,869 - $95,763/Yr

Elevance Health - Louisville, KY

Full-time - Entry Level

Hybrid - Louisville, KY

11-50 employees

Insurance Carriers and Related Activities

About the position

The Clinical Provider Auditor I at Carelon Payment Integrity is responsible for 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 requires a strong understanding of medical coding and billing guidelines, as well as the ability to stay updated on relevant laws and regulations.

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 new healthcare-related questions to aid in investigations.
• Collaborate with the Special Investigation Unit and other internal areas on matters of mutual concern.
• Recommend possible interventions for loss control and risk avoidance.

Requirements

• Requires an AA/AS and a minimum of 1 year related medical coding/auditing experience.
• Must achieve coding certification (CPC, CCS, CPMA) within one year of starting in this position.

Nice-to-haves

• Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology is strongly preferred.
• Coding certificate (CPS, CCS, or CPMA) highly desired.

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution
• Paid holidays
• Paid Time Off
• Medical, dental, vision benefits
• Short and long term disability benefits
• Life insurance
• Wellness programs
• Financial education resources