Senior Clinical Provider Auditor – Payment Integrity

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; or any combination of education and experience, which would provide an equivalent background.
• 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 and 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