Senior Clinical Provider Auditor – Payment Integrity SIU

Role Overview

• 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 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

Requirements

• Requires a AA/AS and minimum of 5 years medical coding/auditing experience, including minimum of 4 years in fraud, waste abuse experience
• Requires coding certification (CPC, CCS, CPMA)
• Prepay review of Medicare and Medicaid experience highly desired
• 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