Clinical Provider Auditor II

This is a fully remote position, open to applicants in Florida, +3 more states.

📋 Description

• Detect issues and/or entities that could present potential risks related to fraud and abuse.

• Analyze claims to ensure adherence to applicable billing and processing standards.

• Identify areas for fraud and abuse prevention and mitigation.

• Review and assess claims and medical records prior to payment execution.

• Utilize necessary systems/tools to accurately log decisions and proceed to the subsequent phase in the claims process.

• Investigate healthcare-related inquiries to support investigations.

• Keep abreast of medical coding and billing matters, trends, and legal/regulatory updates.

• Collaborate with the Special Investigation Unit and other internal departments.

• Suggest interventions for loss control and risk management based on investigative findings.

• Assist in training new team members.

⛳️ Requirements

• AA/AS degree with at least 3 years of experience in medical coding/auditing, including a minimum of 1 year focused on fraud and abuse; or a combination of education and experience that offers an equivalent background.

• Coding certification (CPC, CCS, CPMA) is required.

• Familiarity with ICD-10 and CPT/HCPC coding standards and terminology is essential.

• Candidates must live within a reasonable commuting distance from the job location unless a legal accommodation is provided.

• Individuals in specific patient/member-facing roles must be vaccinated against COVID-19 and Influenza unless a valid exemption is submitted.

• A Bachelor's degree is highly preferred.

🏝️ Benefits

• Merit increases.

• Paid holidays.

• Paid Time Off.

• Incentive bonus programs.

• Medical benefits.

• Dental benefits.

• Vision benefits.

• Short-term disability benefits.

• Long-term disability benefits.

• 401(k) match.

• Stock purchase plan.

• Life insurance.

• Wellness programs.

• Financial education resources.

• Virtual full-time work, except for mandatory in-person training sessions.