Claim 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 Auditor to join our team!

As a Claims Auditor, you will be responsible for pre and 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, implementing performance improvement plans, managing performance guarantee service level agreements, and ensuring reports are complete and distributed timely. 

What you’ll do:
Working under guidance of the Claims Manager you will, 

• Perform audits of claims ensuring processing 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.

• Complete reporting of audits completed, with decision methodology for procedural and monetary errors which are used for quality reporting and trending analysis utilizing the QA Tool.

• Responsible to communicate adjustments to Examiners as identified on pre-payment audits, and to verify adjustment is complete and accurate.

• Identify trends based on the quality reviews, identify quality improvement opportunities and partners with training team to develop programs.

• May adjudicate high dollar claims and/or audit for accuracy logging results in the QA Tool.

• Confer with Claim QA Lead, Claim Operations Managers, Claim Supervisors, 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:

• Minimum of three (3) years of experience as a claim examiner with self-funded health care plans and processing in a TPA environment, meeting production and quality goals/ standards

• High School diploma or GED required, associates or bachelor’s degree preferred.

• Detailed knowledge of relevant systems and proven understanding of processing principles, techniques, and guidelines.

• Ability to acquire and perform progressively more complex skills and tasks in a production environment.

• Experience with a highly automated and integrated claim adjudication system, El Dorado-Javelina preferred but not required.

• Proficient experience in MS Word, Excel, Outlook, and PowerPoint required.

• Ability to work under limited supervision and provide guidance and coaching to others.

• Excellent coaching skills and ability to mentor others towards quality improvement.

• Strong analytical, organizational, and interpersonal skills, with the ability to communicate effectively with others.

• Attention to details, organized, quality and productivity driven.

Location:

This role is located in our downtown Buffalo, NY office with an opportunity for some work from home days.

Who we are:

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.

Headquartered in Buffalo, NY with offices in New York City and Buffalo, Centivo is backed by leading healthcare and technology investors, including a recent round of investment from Morgan Health, a business unit of JPMorgan Chase & Co.