Position Purpose: The Delegation Oversight Compliance Auditor – Medical Claims is responsible for scheduling, coordinating, and conducting delegated entity audits using established audit tools for assigned lines of business. This position is also responsible for ongoing monitoring of assigned delegated entities and collection, as well as data entry for required reporting. This position works independently in the field with extensive provider contact, organizes work and audit schedules, and ensures contract requirements are met and maintained.
- Responsible for managing the audit process from scheduling, conducting the audit, developing corrective action plans, reporting findings as required to internal departments, and communicating recommendations to delegated entity for claims processing, credentialing and/or recredentaling processes.
- Based on CAPs issued, responsible for all follow up audits and educational trainings to ensure delegated entity can achieve compliance.
- Conducts on site visits to assess operational abilities, makes recommendation for improvement and monitors progress with corrective action plan.
- Works in conjunction with management to determine the need and criteria to initiate the annual and focused audit process.
- Ability to work with other internal departments in the development of additional CAPs (e.g. Provider Network Management, Finance).
- Conducts audit using established tools based on contracting and regulatory requirements and consistent with compliance standards.
- Develops and maintains matrices of audit results and scheduled audits.
- Responsible for data entry of all audit related functions.
- Documents findings as required by policy/procedure and consistent with compliance standards.
- Other duties as assigned.
Education/Experience:
- Associate’s degree required; Bachelor’s degree in related field preferred.
- Three years experience working for an HMO, medical group/IPA or hospital claims/credentialing department.
- Previous experience in provider relations and auditing is preferred.
- Previous experience in medical claims processing or auditing is strongly preferred
- Excellent written and verbal communication
License/Certification:
- Valid Driver’s license in the state of residence
Pay Range: $54,000.00 – $97,100.00 per year
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual’s skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.