Clinical Provider Auditor II – Payment Integrity

Role Overview

• Examines claims for compliance with relevant billing and processing guidelines
• Identifies opportunities for fraud and abuse prevention and control
• Reviews and conducts analysis of claims and medical records prior to payment
• Uses required systems/tools to accurately document determinations
• Researches new healthcare related questions as necessary to aid in investigations
• 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
• Recommends possible interventions for loss control and risk avoidance based on investigation outcomes
• Assists with training of new associates

Requirements

• Requires a AA/AS and minimum of 3 years medical coding/auditing experience
• Requires minimum of 1 year in fraud, waste abuse experience
• Requires coding certification (CPC, CCS, CPMA)
• Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology
• Bachelor’s degree strongly preferred

Benefits

• merit increases
• paid holidays
• Paid Time Off
• incentive bonus programs
• medical
• dental
• vision
• short and long term disability benefits
• 401(k) +match
• stock purchase plan
• life insurance
• wellness programs
• financial education resources