Anthem, Inc. Provider Auditor Sr in Reston, Virginia
SHIFT: Day Job
Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.
This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health care companies and a Fortune Top 50 Company.
Location: 100% Remote
Conducts desk audits using medical records, and providers contracts, to ensure that a claim is paid in accordance with the contract, provider reimbursement policies, and industry standards.
Responsible for identifying, monitoring, and analyzing aberrant patterns of utilization and/or fraudulent activities by health care providers through post payment auditing, and provider record review.
Identifies and Investigates potential fraud and over-utilization by performing medical reviews via post payment auditing.
Correlates review findings with appropriate actions (provider education, recovery of monies, cost avoidance).
Assists with development of audit tools, policies and procedures and educational materials.
Acts as a liaison with service operations as well as other areas of the company relative to claims reviews and their status.
Analyzes and trends performance data and works with service operations to improve processes and compliance.
Notifies areas of identified problems or providers, recommending modifications to medical policy and online policy edits.
Communication with providers, and Provider Solutions, regarding issues with selected claims for post payment reviews.
Assists investigators by providing medical review expertise to accomplish the detection of fraudulent activities. Serves as a resource to other nurse auditors.
- Requires either a BA/BS degree, medical coding certification and a minimum of 3 years equivalent work experience; or any combination of education and experience, which would provide an equivalent background.
RN or medical coding certification strongly preferred.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws. Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Applicants who require accommodation to participate in the job application process may contact firstname.lastname@example.org for assistance.