Centivo is hiring a Claims QA Auditor to join our mission of bringing affordable, high-quality healthcare to millions. In this role, you will conduct pre-payment, post-payment, and adjudication audits across multiple employer groups and products, focusing on complex high-dollar claims. You will manage all aspects of the Claims Quality Review program, from establishing standards to implementing performance improvements.

What You'll Do

Audit claims to ensure processing, payment, and financial accuracy, verifying compliance with standard processes and client summary plan descriptions.
Complete audit reporting with decision methodology for procedural and monetary errors, using QA tools for quality reporting and trending analysis.
Communicate corrections and adjustments to Examiners from pre-payment audits, including high-dollar claims, and verify their completion and accuracy.
Identify and escalate quality trends based on review findings.
Confer with Claims QA Lead, Supervisors, Managers, and Training Lead on issues requiring immediate corrective action.
Investigate and research issues to create or improve standard processing guidelines, and participate in projects as a subject matter expert.
Perform additional tasks as necessary, such as processing claims, creating policies, training, and mentoring examiners through quality improvement plans.

What We're Looking For

High School diploma or GED.
Minimum of three (3) years as a claim examiner and/or auditor with self-funded health care plans in a TPA environment, meeting production and quality goals.
Proficient experience in MS Word, Excel, Outlook, and PowerPoint.
Detailed knowledge of relevant systems and a proven understanding of processing principles, techniques, and guidelines.
Strong analytical, organizational, and interpersonal skills with effective communication abilities.
Attention to detail, organized, quality and productivity driven.

Nice to Have

Associate or bachelor’s degree.
Prior experience with a highly automated claims system like El Dorado-Javelina or Health Rules Payer (HRP).
Ability to acquire and perform progressively more complex skills in a production environment.
Ability to work under limited supervision and provide guidance and coaching to others.
Excellent coaching skills and ability to mentor others towards quality improvement.