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Clinical Provider Auditor II-Remote

Company: Anthem
Location: Wilmington
Posted on: November 13, 2019

Job Description:

Clinical Provider Auditor II-Remote (PS28974)Location: United StatesRequisition #: PS28974Post Date: Oct 31, 2019Clinical Provider Auditor II PS28974This position has the ability to work remoteResponsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.Primary duties may include, but are not limited to:

  • 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.
  • Assists with training of new associates.Qualifications:
    • Requires an Associate or Bachelors degree or equivalent combination of education and experience.
    • Must possess coding certification (CPC, CCS, CPMA) and have knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology.
    • 4 years medical coding/auditing experience; 1 years in fraud, waste abuse experience.AnEqualOpportunityEmployer/Disability/Veteran

Keywords: Anthem, Wilmington , Clinical Provider Auditor II-Remote, Other , Wilmington, Delaware

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