Clinical Provider Auditor II - Payment Integrity SIU

About the role

The Clinical Provider Auditor II is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse. This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy.

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.
• Affords support to the Special Investigation Unit by assisting with training of new associates.

Requirements

• Requires a AA/AS and minimum of 3 years medical coding/auditing experience, including minimum of 1 year 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.

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.

Qualifications

• Requires a AA/AS and minimum of 3 years medical coding/auditing experience, including minimum of 1 year 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.

Skills

• Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology.
• Bachelor’s degree in healthcare, medical coding, or related field.
• Experience with fraud, waste abuse, and prepay review of Medicare and Medicaid.

Benefits

• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase.
• 401(k) contribution.

Pay

The salary* range for this specific position is $58,400 to $107,740. Locations: Virginia

Schedule

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy.