Clinical Provider Auditor Lead - Maryland Behavioral Health

About the role

The Clinical Provider Auditor Lead supports Payment Integrity and Behavioral Health Carelon, a healthcare services organization that focuses on integrating physical, behavioral, social, and pharmacy services. The role involves leading the audit program for a region, managing vendor relationships, conducting provider meetings, and assisting in reimbursement initiatives.

Responsibilities

• Leads day-to-day activities of the audit team, allocating resources and setting priorities.
• Manages vendor relationships with contracted vendors.
• Audits vendor work and ensures compliance with contract terms.
• Conducts provider meetings to discuss audit findings and appeals.
• Negotiates settlements and adjusts/reprices claims based on audit findings.
• Researches claims payment methodologies and fee schedules.
• Assists in resolving contractual issues with providers and reviewing audit processes.
• Prepares and analyzes reports to demonstrate recoveries and potential issues.
• Supports reimbursement/audit initiatives as needed.

Requirements

• BA/BS with minimum 5 years of related experience in provider audit, reimbursement, or a combination of education and experience.
• Experience in medical coding, including coding certification and a clinical background, is preferred.
• Project management and leadership experience are highly valued.
• Behavioral Health coding and auditing experience is preferred.
• Coding certification (CPC, CCS, CPMA) is preferred.

Qualifications

• Minimum qualifications include a BA/BS and 5 years of related experience.

Skills

• Strong leadership and project management skills.
• Excellent communication and negotiation abilities.
• Proficiency in medical coding and billing.
• Ability to conduct thorough audits and analyze data.

Benefits

Elevance Health offers a comprehensive benefits package, including a competitive salary range ($76,608.00 - $95,760.00 annually), incentive and recognition programs, equity stock purchase, and a 401(k) match. Additional benefits include a comprehensive benefits package, flexible work arrangements, and a commitment to equal pay opportunities for equal work.

Pay

The salary range for this specific position is $76,608.00 - $95,760.00 annually. The actual salary may vary based on location, experience, and performance.

Schedule

This role is field-based, requiring travel to client sites or designated locations as needed, with occasional office attendance for meetings or training.