Clinical Provider Auditor
Listed on 2026-10-17
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Healthcare
Medical Billing and Coding, Healthcare Compliance
Clinical Provider Auditor I
Location:
This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.
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 is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.
How you'll make a difference:
- 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, qualifications and experiences:
- Knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology strongly preferred.
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