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Elevance Health
Clinical Provider Auditor IElevance Health • Tampa, FL, United States
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Clinical Provider Auditor I

Clinical Provider Auditor I

Elevance Health • Tampa, FL, United States
30+ days ago
Job type
  • Full-time
Job description

Clinical Provider Auditor I

This position is virtual eligible, but you must be within a reasonable commute of one of our offices. General business hours, Monday through Friday (ET). This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Clinical Provider Auditor I is responsible 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.

Required Qualifications

  • Requires a AA/AS and minimum of 1 year related medical coding/auditing experience; or any combination of education and experience, which would provide an equivalent background.
  • Must achieve coding certification (CPC, CCS, CPMA) within one year of starting in this position.

Preferred Qualifications

  • Current CPC certification very strongly preferred.
  • Prior auditing experience is a must for this role!
  • Facility and/or behavioral health experience is preferred.
  • Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology strongly preferred.
  • You must have a strong team spirit and a collaborative mentality.

Non-Management Non-Exempt

1st Shift (United States of America)

FRD > Audit

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Clinical Provider Auditor I • Tampa, FL, United States

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