Clinical Provider Auditor II - Payment Integrity SIU

Clinical Provider Auditor II – Payment Integrity SIU role responsible for examining claims for compliance with billing and processing guidelines and identifying opportunities to prevent fraud and abuse. Responsibilities include reviewing claims and medical records prior to payment, documenting determinations using required systems, researching healthcare questions, collaborating with the Special Investigation Unit, recommending interventions to reduce loss, and assisting with training new associates. Work is hybrid with 1-2 days in-office weekly; alternate locations may be considered within commuting distance. Knowledge of ICD-10 and CPT/HCPCS coding guidelines is preferred; prepay review experience and a Bachelor’s degree are strongly preferred. The role emphasizes identifying issues that pose risk, staying current with regulatory changes, and supporting investigations and risk avoidance.