Perform auditing of claims (for internal and external constituents), ensuring processing, payment, and financial accuracy by verifying all aspects of the claim have been handled correctly and according to both standard process and the client’s summary plan description.
Completes reporting of audits finalized with decision methodology for procedural and monetary errors, which are used for quality reporting and trending analysis utilizing QA tools.
Responsible to communicate corrections and adjustments to Claims Adjustors as identified on pre-payment audits, including high-dollar claims, and to verify corrections and adjustments are complete and accurate.
Identify and escalate trends based on the quality reviews.
Confer with Claims QA Lead, Claims Supervisors, Claim Managers, and/or Training Lead on any problematic issues warranting immediate corrective action.
May investigate and research issues as required to create or improve standard processing guidelines and may participate in projects as a subject matter expert as needed.
Perform any other additional tasks as necessary, including processing of claims, creating policies, training, and/or mentoring Claims Adjustors through quality improvement plans.
Qualification
Strong analyticalAttention to detailsEducation and ExperienceHigh School diploma or GED requiredProficient experience in MS WordResilient – This is wicked hardPositive – We care about each other
Required
Prior experience with a highly automated and integrated claims processing system, El Dorado-Javelina or Health Rules Payer (HRP) preferred.
Detailed knowledge of relevant systems and proven understanding of processing principles, techniques, and guidelines.
Strong analytical, organizational, and interpersonal skills, with the ability to communicate effectively with others.
Attention to details, organized, quality and productivity driven.
Education and Experience:
High School diploma or GED required.
Associate or bachelor’s degree preferred.
Minimum of three (3) years of experience as a claim adjustor and/or auditor with self-funded health care plans and processing in a TPA environment, meeting production and quality goals/ standards.
Proficient experience in MS Word, Excel, Outlook, and PowerPoint required.
Preferred
Ability to acquire and perform progressively more complex skills and tasks in a production environment.
Ability to work under limited supervision and provide guidance and coaching to others.
Excellent coaching skills and ability to mentor others towards quality improvement.
Candidates located within commuting distance of our Buffalo office will be considered for both in-person and hybrid roles. All other applicants will be considered for remote positions.
Resilient – This is wicked hard. There is no easy button for healthcare affordability. Luckily, the mission makes it worth it and sustains us when things are tough. Being resilient ensures we don’t give up.
Uncommon - The status quo stinks so we had to go out and build something better. We know the healthcare system. It isn't working for members, employers, and providers. So we're building it from scratch, from the ground up. Our focus is on making things better for them while also improving clinical results - which is bold and uncommon.
Positive – We care about each other. It takes energy to do hard stuff, build something better and to be resilient and unconventional while doing it. Because of that, we make sure we give kudos freely and feedback with care. When our tank gets low, a team member is there to be a source of new energy. We celebrate together. We are supportive, generous, humble, and positive.
Centivo is an innovative health plan for self-funded employers on a mission to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills. Anchored around a primary care based ACO model, Centivo saves employers 15 to 30 percent compared to traditional insurance carriers. Employees also realize significant savings through our free primary care (including virtual), predictable copay and no-deductible benefit plan design. Centivo works with employers ranging in size from 51 employees to Fortune 500 companies. For more information, visit centivo.com.
