Claims QA Auditor

Buffalo, New York, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Candidates must possess a High School diploma or GED, with an Associate or Bachelor's degree preferred. A minimum of three years of experience as a claim examiner and/or auditor with self-funded health care plans and processing in a TPA environment is required, along with proficiency in MS Word, Excel, Outlook, and PowerPoint. Prior experience with a highly automated and integrated claims processing system, such as El Dorado-Javelina or Health Rules Payer (HRP), is preferred. Strong analytical, organizational, and interpersonal skills are necessary, as is a keen attention to detail.

Responsibilities

The Claims QA Auditor will perform pre-payment, post-payment, and adjudication audits of claims, ensuring accuracy and compliance with processing standards and client agreements. This includes identifying and communicating corrections, escalating trends, and conferring with leads and managers on problematic issues. The role may involve investigating issues to improve processing guidelines, participating in projects as a subject matter expert, and performing additional tasks such as processing claims, creating policies, training, and mentoring examiners.

Skills

Centivo

Affordable health insurance with primary care focus

About Centivo

Centivo provides health insurance focused on making healthcare affordable and accessible. The company emphasizes primary care, offering free primary care services, no deductibles, and low, predictable copays to help keep its members healthier and reduce the need for hospital visits. Centivo generates revenue by charging employers for health plans provided to their employees, which leads to lower medical costs and increased usage of the plans. A key feature of Centivo's offering is its integrated virtual care service, allowing members to access care conveniently. The company is distinguished by its commitment to quality, curating providers based on strict price and quality standards, particularly in primary care. Centivo's goal is to enhance the member experience while lowering overall healthcare costs.

Buffalo, New YorkHeadquarters

2017Year Founded

$183.7MTotal Funding

DEBTCompany Stage

Financial Services, HealthcareIndustries

201-500Employees

Benefits

Insurance: Medical, dental, vision, life & diability

401k plan

Access to a health savings account

Commuting and dependent care FSA

Competitive salary, bonus, & equity

Risks

Integration challenges with Eden Health may disrupt service delivery if not managed well.

Chronic shortages in primary care access could impact Centivo's care delivery model.

Increased competition from AI-driven startups may challenge Centivo's market position.

Differentiation

Centivo emphasizes primary care partnerships to coordinate healthcare needs effectively.

The company offers free primary care, no deductibles, and low, predictable copays.

Centivo integrates virtual care and mental health services for comprehensive healthcare solutions.

Upsides

Centivo raised $75M to expand affordable health plans amid rising U.S. healthcare costs.

Acquisition of Eden Health enhances Centivo's virtual care and mental health services.

Growing trend of virtual care aligns with Centivo's integrated virtual care service.

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