Clinical Provider Auditor Senior - Payment Integrity SIU
Anticipated End Date:2026-08-07Position Title:Clinical Provider Auditor Senior - Payment Integrity SIUJob Description:Clinical Provider Auditor II – Payment Integrity SIULocation: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are care providers, engineers, data scientists, and other dedicated professionals determined to recover, eliminate and prevent unnecessary medical-expense spending.The Clinical Provider Auditor Senior will be 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 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.Minimum 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).Preferred Experience: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.Job Level:Non-Manag...