Clinical Provider Auditor I - Maryland Behavioral Health

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.

About the role

The Clinical Provider Auditor I will be responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse. This field-based role enables associates to primarily operate in the field, traveling to client sites or designated locations as their role requires, with occasional office attendance for meetings or training. The ideal candidate would need to reside within the state of Maryland and within distance of our Hanover, MD Pulse Point. Candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

Responsibilities

• 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.

Requirements

• Requires an AA/AS and minimum of 1 year related medical coding/auditing experience; or any combination of education and experience, which would provide an equivalent background.
• Must achieve coding certification (CPC, CCS, CPMA) within one year of starting in this position.

Skills

• Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology strongly preferred.
• Behavioral Health coding and auditing experience preferred.

Pay

For candidates working in person or virtually in Maryland, the salary range for this specific position is $28.75/hr. - $35.94/hr. The salary offered is based on a number of legitimate, non-discriminatory factors set by the Company, including geographic location, work experience, education, and skill level.

Benefits

In addition to your salary, Elevance Health offers a comprehensive benefits package, including:

• Incentive and recognition programs
• Equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements)
• Medical, dental, vision, short and long term disability benefits
• 401(k) + match
• Stock purchase plan
• Life insurance
• Wellness programs and financial education resources
• Paid holidays and Paid Time Off (unless covered by a collective bargaining agreement)

Schedule

Elevance Health operates in a Hybrid Workforce Strategy. Associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.