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.
Technical Stack
- MS Word
- Excel
- Outlook
- PowerPoint
Team & Environment
You will work closely with the Claims QA Lead, Claims Supervisors, Claim Managers, and the Training Lead.
Work Mode
This is a hybrid role based in Buffalo.
Centivo is an equal opportunity employer.
