Provider Reimbursement Auditor

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
 

Position Purpose: The Provider Reimbursement Auditor is responsible for conducting comprehensive audits of provider claims to ensure accurate reimbursement and compliance with contractual, regulatory, and policy guidelines. This position requires detailed analysis of claim documentation, provider contracts, billing manuals, and eligibility/enrollment data to identify payment errors, determine root causes, and recommend corrective actions. The auditor also plays a key role in maintaining audit standards and supporting continuous process improvement.

• Conduct quality audits of provider claims, pre and post payments, utilizing appropriate sources of information, including eligibility, enrollment, state contracts, provider and facility contracts, and state and health plan billing manuals

• Analyze errors and determine root causes for appropriate error responder assignment.

• Utilize audit software to provide written documentation regarding audit observations

• Analyze and review responses to audit observations to validate accuracy.

• Provide updates to audit criteria including maintaining state ACME, reviewing state website for updates, documenting business decisions, identifying required updates for department pricing tools, etc.
• Performs other duties as assigned

• Complies with all policies and standards

Education/Experience: Associate’s degree in related field or equivalent experience. 2+ years of medical or pharmacy claims processing or claims pricing experience. Medicaid and Medicare reimbursement rules and the ability to interpret state and provider contracts preferred. Knowledge of CPT/HCPCS Coding preferred.

Preferred Skills:

Proficient in Microsoft Excel and Word

Proficient audit software tools

2–4 years of experience in provider claims auditing, medical billing, or reimbursement

Knowledge of Medicaid, Medicare, and commercial payer systems

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, including full-time or part-time status.  Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act