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Clinical Provider Auditor II, Sr.-Remote

Company: Anthem
Location: Savannah
Posted on: November 10, 2019

Job Description:

Clinical Provider Auditor II, Sr.-Remote (PS28975)Location: United StatesNewRequisition #: PS28975Post Date: 5 days agoYour Talent. Our Vision. At Anthem, Inc.,its a powerful combination, and the foundation upon which were creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.This is an exceptional opportunity to do innovative work that means more to you and those we serve atone of America's leading health benefits companies and a Fortune Top 50 Company.Clinical Provider Auditor II, Sr.This position has the ability to work remote. This position can be filled at either the Clinical Provider Auditor II or at the Sr. level.Clinical Provider Auditor IIResponsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.Primary duties may include, but are not limited to:

  • 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 claims lifecycle.
  • Researches 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.Clinical Provider Auditor Sr.Responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.Primary duties may include, but are not limited to:
    • Examines claims for compliance with relevant billing and processing guidelines and identifies opportunities for fraud and abuse prevention and control.
    • Review 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 claims lifecycle.
    • Researches 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 to determine patterns of billing behavior.
    • Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation.
    • Trains new associates.
    • Develops, designs and implements new or revised methods to improve the operations.Qualifications:Clinical Provider Auditor II
      • Requires an Associate or Bachelors degree or equivalent combination of education and experience.
      • Must possess coding certification (CPC, CCS, CPMA) and have knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology.
      • 4 years medical coding/auditing experience; 1 years in fraud, waste abuse experience.Clinical Provider Auditor Sr.
        • Requires an Associate or Bachelor's degree or equivalent combination of education and experience.
        • Must possess coding certification (CPC, CCS, CPMA) and have knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology.
        • 6+ years medical coding/auditing experience; 4+ years in fraud, waste abuse experience.Anthem, Inc. is ranked as one of Americas Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.

Keywords: Anthem, Savannah , Clinical Provider Auditor II, Sr.-Remote, Healthcare , Savannah, Georgia

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