Clinical Provider Auditor II
Core
Examines claims for compliance with billing guidelines to identify fraud, waste, and abuse risks before payment.
Role type
Senior IC clinical provider auditor (fraud & abuse)
Builds
Fraud prevention controls and loss avoidance interventions
Domain
Healthcare insurance / Medical billing & coding
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medical coding/auditing, fraud investigation, claims analysis, medical record review, regulatory research, loss control recommendations
Preferred skills
ICD-10 coding, CPT/HCPC coding guidelines, bachelor's degree
Technologies
Required systems/tools for claims documentation
Responsibilities
Examines claims for compliance with billing guidelines, reviews claims and medical records prior to payment, researches healthcare laws and coding trends, collaborates with Special Investigation Unit, recommends interventions for loss control, assists with training new associates
Seniority
Mid-level, hands-on IC
