Claims QA Auditor

Role Summary

The Claims QA Auditor is primarily responsible for pre-payment, post-payment, and adjudication audits of claims across multiple employer groups and products, including complex high-dollar claims. This includes handling all aspects of the Claims Quality Review program, establishing processing standards, responding to quality issues, assisting in implementing performance improvement plans, providing data for performance guarantee service level agreements, and assisting with ensuring reports are completed and distributed timely.

Salary: $55K - $60K Employment Type: FullTime Location Type: Hybrid

Responsibilities

• Perform auditing of claims, 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 Examiners 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 examiners through quality improvement plans.

Required Skills and Abilities

• 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 detail, 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 examiner and/or auditor with self-funded healthcare plans and processing in a TPA environment, meeting production and quality goals/ standards.
• Proficient experience in MS Word, Excel, Outlook, and PowerPoint required.

Preferred Qualifications

• 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.

Work Location

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.

About Centivo

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.