Claims QA Auditor

We exist for workers and their employers — who are the backbone of our economy. That is where Centivo comes in — our mission is to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills.

Centivo is looking for a Claims QA Auditor to join our team!

As a Claims QA Auditor your will be 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.

What you’ll do:

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.
You should have:

Prior experience with a highly automated and integrated claims processing system.
Minimum of three (3) years of experience as a claim examiner and/or auditor with self-funded health care plans and processing in a TPA environment, meeting production and quality goals/ standards.
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.
High School diploma or GED required.
Associate or bachelor’s degree preferred.
Proficient experience in MS Word, Excel, Outlook, and PowerPoint required.
These are not required, but would be nice to have:

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:

This position is remote.
Pay Transparency
The ranges we place in our job postings reflect what we anticipate to be the minimum to maximum of the base salary for this role. Additionally, our overall benefits package includes a few things you may consider towards a total compensation such as bonus, health benefits (some employer paid), PTO, and equity option grants.

Salary Range
$47,000—$51,000 USD