About the role
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 seeking a Claims Auditor who will be responsible for conducting pre-payment, post-payment, and claims adjudication audits across multiple employer groups and product lines, including complex, high-dollar claims. This role plays a key part in maintaining the integrity of our claims operations by supporting all aspects of the Claims Quality Review program, establishing processing standards, responding to quality findings, assisting with performance improvement plans, and providing data to support service level agreements (SLAs). The Claims Auditor will also help ensure that audit reports are completed accurately and distributed in a timely manner.
Responsibilities Include: Perform auditing of claims (for internal and external constituents), 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 Claims Adjustors 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 Claims Adjustors through quality improvement plans.
