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Clinical Provider Auditor I (Remote)

Company: Anthem, Inc
Location: Modesto
Posted on: March 28, 2020

Job Description:

Clinical Provider Auditor I (Remote) (PS34763)Location: United StatesNewRequisition #: PS34763Post Date: 13 hours agoYour Talent. Our Vision. At Anthem, Inc ., its a powerful combination, and the foundation upon which were creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health benefits companies and a Fortune Top 50 Company.Clinical Provider Auditor IThis role 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.
  • Requires an Associate degree or equivalent combination of education and experience.
  • Must also achieve coding certification (CPC, CCS, CPMA) within 6 months of starting in this position and have knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology.
  • 1- 3 years related medical coding/auditing experience, no prior fraud/waste abuse experience necessary.Anthem, Inc. is ranked as one of Americas Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.

Keywords: Anthem, Inc, Modesto , Clinical Provider Auditor I (Remote), Healthcare , Modesto, California

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