Clinical Provider Auditor I role at Elevance Health focusing on fraud and abuse prevention in claims. Responsibilities include compliance examination and collaboration with internal teams.
Responsibilities
Identifying issues and/or entities that may pose potential risk associated with fraud and abuse
Examines claims for compliance with billing and processing guidelines
Conducts analysis of claims and medical records prior to payment
Collaborates with the Special Investigation Unit and other internal areas
Recommends possible interventions for loss control and risk avoidance
Requirements
AA/AS and minimum of 1 year related medical coding/auditing experience
Coding certification (CPC, CCS, CPMA) within one year of starting
Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology strongly preferred
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