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Anthem, Inc Clinical Provider Auditor II - PS25993 in Deerfield, Illinois

Clinical Provider Auditor II - PS25993

Location: United States


Requisition #: PS25993

Post Date: 4 days ago

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 benefits companies and a Fortune Top 50 Company.

This position may be located at any Anthem location or can be remote.

The Clinical Provider Auditor II is responsible for identifying issues and/or entities that may pose potential risk associated with fraud and abuse.

Primary duties may include, but are not limited to:

  • 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.

  • Assists with training of new associates.


  • Requires an Associate or Bachelor's degree or equivalent combination of education and experience.

  • Must possess coding certification (CPC, CCS, CPMA) and have knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology.

  • 4 years medical coding/auditing experience required

  • 1 years in fraud, waste abuse experience preferred. RN preferred.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran.