Clinical Provider Auditor II

About the role

Primary location: Atlanta, GA. This role is virtual full‑time except for required in‑person training sessions, offering maximum flexibility and autonomy while ensuring essential face‑to‑onboarding and skill development. Alternate locations may be considered for candidates within a reasonable commuting distance; otherwise, accommodation may be granted as required by law. The Clinical Provider Auditor II identifies issues and/or entities that may pose potential risk associated with fraud and abuse.

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 the next step in the claims lifecycle.
• Researches new healthcare‑related questions as needed to aid 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 investigation outcomes.
• Assists with training of new associates.

Requirements

• Associate’s degree (AA/AS) and a minimum of 3 years of medical coding/auditing experience, including at least 1 year in fraud, waste, and abuse experience; or any equivalent combination of education and experience.
• Current coding certification (CPC, CCS, or CPMA).

Qualifications

• Knowledge of ICD‑10 and CPT/HCPC coding guidelines and terminology.
• Bachelor’s degree strongly preferred.

Benefits

• Merit increases
• Paid holidays
• Paid Time Off (PTO)
• Incentive bonus programs (unless covered by a collective bargaining agreement)
• Medical, dental, and vision coverage
• Short‑ and long‑term disability benefits
• 401(k) with company match
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources

Schedule