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Provider Auditor/Auditor Sr

Company: Anthem
Location: Baltimore
Posted on: November 17, 2019

Job Description:

Provider Auditor/Auditor Sr (PS24693)Location: Cerritos, California, United StatesRequisition #: PS24693Post Date: Oct 30, 2019Your 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 healthcare.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.Provider Auditor- PS24693This position can be filled at either the Provider Auditor or the Provider Auditor Sr. level depending on experience and skillset.Location: Off Premises Work and local in Cerritos, CA.Conducts on-site reviews of medical charts, medical notes, itemized bills and providers contracts to ensure that a claim is paid in accordance with the contract, provider reimbursement policies, and industry standards.Primary duties may include, but are not limited to:

  • Selects providers to be reviewed based on historical results of other reviews with providers, network management input and dollar volume of provider.
  • Schedules review with provider, analyzes data to select claims to be reviewed, conducts review using medical charts, medical notes, itemized bills and provider contracts.
  • Conducts exit interview with provider management team by presenting preliminary review results.
  • Verifies dollar amount on claim is correct in claims system and writes report of the findings of the review and requests payments for any overpayments.
  • Identifies aberrant patterns of billing and detects potential abuse.
  • Participates in developing and/or reviewing department policies and procedures.
  • Works on task forces and committees.Provider Auditor Sr.Location: Off Premises Work and local in Cerritos, CA.Performs reviews of medical charts, medical notes, itemized bills and providers contracts to ensure that a claim is paid in accordance with the contract, provider reimbursement policies, and industry standards.Primary duties may include, but are not limited to:
    • Assists in identifying providers to be reviewed based on historical results of other reviews with providers, network management input and dollar volume of provider.
    • Assists with virtual review with provider, analyzes data to select claims to be reviewed, conducts review using medical charts, medical notes, itemized bills and provider contracts.
    • Conducts exit interview with provider management team by presenting preliminary review results.
    • Verifies dollar amount on claim is correct in claims system and writes report of the findings of the review and requests payments for any overpayments. Identifies aberrant patterns of billing and detects potential abuse.
    • Mentors and trains Provider Auditor as needed.
    • Drafts department policies and procedures and other educational materials.
    • Workson task forces and committees representing functional area.Qualifications:Provider Auditor
      • Requires either a BA/BS degree or Registered Nurse; certification in a clinical practice or medical coding or provider reimbursement auditing or 2-4 years equivalent work experience
      • Or any combination of education and experience, which would provide an equivalent background.
      • RN or medical coding certification preferred.
      • Must be able to travel at least 25% required (to Cerritos, CA if the associate is WAH).Provider Auditor Sr.
        • Requires either a BA/BS degree or Registered Nurse; Certification in a clinical practice or medical coding or provider reimbursement auditing or 5 years equivalent work experience
        • Or any combination of education and experience, which would provide an equivalent background.
        • RN or medical coding certification preferred.
        • At least 25%travel required (to Cerritos, CA if the associate is WAH).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. AnEqualOpportunityEmployer/Disability/Veteran

Keywords: Anthem, Reading , Provider Auditor/Auditor Sr, Accounting, Auditing , Baltimore, Pennsylvania

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