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Centivo · 1 month ago

Claims Auditor

Buffalo, NY

Full-time

Onsite

Mid Level

$52K/yr - $60K/yr

3+ years exp

Centivo is an innovative health plan for self-funded employers focused on providing affordable, high-quality healthcare. The Claims Auditor will conduct audits across multiple employer groups, ensuring the integrity of claims operations and supporting the Claims Quality Review program.

Health CareInformation TechnologyMedical

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

Qualification

Claims processing systemsClaims auditing experienceAnalytical skillsMS WordMS ExcelHealth Rules PayerCoaching skillsInterpersonal skillsOrganizational skillsAttention to detail

Required

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 details, organized, quality and productivity driven

High School diploma or GED required

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

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