Clinical Provider Auditor II - Maryland Behavioral Health

$64,680 - $92,610/Yr

Elevance Health - Hanover, MD

Full-time - Mid Level

Hanover, MD

5,001-10,000 employees

Insurance Carriers and Related Activities

About the position

The Clinical Provider Auditor II plays a crucial role in supporting Payment Integrity and Behavioral Health at Elevance Health. This position is responsible for identifying potential risks associated with fraud and abuse in medical billing and coding. The auditor examines claims for compliance, conducts analyses of claims and medical records, and collaborates with internal teams to recommend interventions for loss control and risk avoidance. The role requires a strong understanding of medical coding and auditing practices, particularly in the context of behavioral health.

Responsibilities

• Examine claims for compliance with relevant billing and processing guidelines.
• Identify opportunities for fraud and abuse prevention and control.
• Review and analyze claims and medical records prior to payment.
• Document determinations accurately using required systems/tools.
• Research healthcare-related questions to aid in investigations.
• 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 mutual concerns.
• Recommend interventions for loss control and risk avoidance based on investigation outcomes.
• Assist with training of new associates.

Requirements

• AA/AS degree and a minimum of 4 years of medical coding/auditing experience, including at least 1 year in fraud, waste, and abuse experience.
• Coding certification (CPC, CCS, CPMA) is required.

Nice-to-haves

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

Benefits

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Employee stock purchase plan
• Health insurance