Clinical Provider Auditor I - Maryland Behavioral Health

Anticipated End Date:

Position Title:

Clinical Provider Auditor I - Maryland Behavioral Health

Job Description:

Clinical Provider Auditor I Supports Payment Integrity & Behavioral Health Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together.

Among us are specialty-care physicians, nurse practitioners, pharmacists, engineers, data scientists, and other dedicated and caring health professionals. While our roles may differ, our purpose is shared: to make a positive impact on whole health. A proud member of the Elevance Health family of companies, Carelon Behavioral Health uses our powerful combination of experience, expertise, dedication and compassion to see what's possible and what's better.

Born out of one of the largest healthcare systems organization in the United States, our rich history gives us a unique and valuable perspective on how to solve the most pressing healthcare challenges.

Location:

The ideal candidate would need to reside within the state of Maryland and within distance our Hanover, MD Pulse Point. Field:
This field-based role enables associates to primarily operate in the field, traveling to client sites or designated locations as their role requires, with occasional office attendance for meetings or training. This approach ensures flexibility, responsiveness to client needs, and direct, hands‑on engagement. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

The Clinical Provider Auditor I will be responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse. How you will make an impact:
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.

Minimum Requirements:

Requires a AA/AS and minimum of 1 year related medical coding/auditing experience; or any combination of education and experience, which would provide an equivalent background. Must achieve coding certification (CPC, CCS, CPMA) within one year of starting in this position.

Preferred Skills, Capabilities and Experiences:
Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology strongly preferred. Behavioral Health coding and auditing experience preferred.

For candidates working in person or virtually in the below locations, the salary
* range for this specific position is $28.75/hr.

- $35.94/hr location:
Maryland. In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

* The salary range is the range Elevance Health in good faith believes is the range of possible…