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Provider Network Management
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PS24693 Requisition #
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 healthcare. 

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.


Provider Auditor Sr - PS24693
Location:  Off Premises Work and local in Cerritos, CA.

Performs reviews of medical charts, medical notes, itemized bills and providers contracts to ensure that a claim is paid in accordance with the contract, provider reimbursement policies, and industry standards. 
  • Primary duties may include, but are not limited to:  
    • Assists in identifying providers to be reviewed based on historical results of other reviews with providers, network management input and dollar volume of provider. 
    • Assists with virtual review with provider, analyzes data to select claims to be reviewed, conducts review using medical charts, medical notes, itemized bills and provider contracts.  
    • Conducts exit interview with provider management team by presenting preliminary review results. 
    • Verifies dollar amount on claim is correct in claims system and writes report of the findings of the review and requests payments for any overpayments. Identifies aberrant patterns of billing and detects potential abuse. o Mentors and trains Provider Auditor as needed. 
    • Drafts department policies and procedures and other educational materials.  Works on task forces and committees representing functional area.

Qualifications:


Requires either a BA/BS degree or Registered Nurse;

  • Certification in a clinical practice or medical coding or provider reimbursement auditing or 5 years equivalent work experience; or any combination of education and experience, which would provide an equivalent background.
  • RN or medical coding certification preferred.
  • At least 25% travel required (to Cerritos, CA if the associate is WAH).
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 careers.antheminc.com.

AnEqualOpportunityEmployer/Disability/Veteran

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This is an exciting opportunity to advance your life and career, while still protecting and serving others. Come see for yourself why Anthem is recognized as a Top Employer by GI Jobs and among the “Best of the Best: Top Veteran Friendly Companies” by US Veterans Magazine.

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