Clinical Provider Auditor I
Core
Examines claims for compliance with billing guidelines to identify fraud, abuse, and errors before payment.
Role type
Medical claims auditor
Builds
Fraud prevention controls and accurate claim determinations
Domain
Healthcare insurance / Medical billing
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medical coding, Claims auditing, ICD-10, CPT/HCPC coding guidelines, Medical records analysis, Billing compliance, Fraud detection, Regulatory research, Data analysis, Risk assessment
Preferred skills
CPC certification, Behavioral health experience, Facility auditing experience, Medical coding trends knowledge
Technologies
Required systems/tools for claims documentation
Responsibilities
Examines claims for compliance with billing guidelines, Reviews and analyzes claims and medical records prior to payment, Researches healthcare questions to aid investigations, Collaborates with Special Investigation Unit, Recommends interventions for loss control and risk avoidance
Seniority
Entry-level, individual contributor