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Clinical Provider Auditor I - SIU Fraud and Abuse
Elevance Health - Metairie, LA
posted about 2 months ago
About the position
The Clinical Provider Auditor I at Elevance Health 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 the Special Investigation Unit to recommend interventions for loss control and risk avoidance. The position operates in a hybrid work model, requiring the candidate to work in the office 1-2 days per week.
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 an AA/AS and minimum of 1 year related medical coding/auditing experience, or any combination of education and experience that provides an equivalent background.
- 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 Time Off
- Medical, dental, and vision insurance
- Short and long term disability benefits
- Life insurance
- Wellness programs
- Financial education resources
