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Clinical Provider Auditor I - SIU Fraud and Abuse
Elevance Health - South Portland, ME
posted 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 is part of Carelon Payment Integrity, which aims to recover and prevent unnecessary medical expenses.
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 to aid in investigations and stay updated on 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 investigations.
Requirements
- Requires an AA/AS and a 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 holidays
- Paid Time Off
- Medical, dental, and vision benefits
- Short and long term disability benefits
- Life insurance
- Wellness programs
- Financial education resources
