Clinical Provider Auditor II

Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.

Carelon Payment Integrity is a proud member of the Elevance Health family of companies, Carelon Insights, formerly Payment Integrity, is determined to recover, eliminate and prevent unnecessary medical-expense spending.

The Clinical Provider Auditor II is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.

How you will make an impact:

• Examines claims for compliance with relevant billing and processing guidelines and identifies opportunities for fraud and abuse prevention and control.

• Reviews and conducts analysis of claims and medical records prior to payment and uses required systems/tools to accurately document determinations and continue to next step in the claim's lifecycle.

• Research new healthcare related questions as necessary to aid in investigations and stays abreast of current medical coding and billing issues, trends and changes in laws/regulations.

• Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern.

• Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation.

• Assists with training of new associates.

Minimum Requirements:

• Requires an AA/AS and minimum of 4 years medical coding/auditing experience, including minimum of 1 year in fraud, waste abuse experience; or any combination of education and experience, which would provide an equivalent background.

• Requires coding certification (CPC, CCS, CPMA).

Preferred Skills, Capabilities and Experiences:

• Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology and bachelor's degree strongly preferred.