Claims Auditor Lead

Centivo is looking for a Claims Auditor Lead to join our team!

As a Claims Auditor Lead you will be primarily responsible for pre and post payment and adjudication audits of high dollar claims across multiple employer groups and products including complex high dollar claims. This includes handling all aspects of the Claims' Quality Review program, establishing processing standards, responding to quality issues, implementing performance improvement plans, managing performance guarantee service level agreements, and ensuring reports are complete and distributed timely.

You will also provide reports to department leaders on inventory, production, turn-around lag and quality results at an examiner, client level and produces client performance guarantees as required.

Accountable for positively influencing the morale of the department, including setting achievable goals, fostering teamwork by involving team members in the design/implementation of solutions to problems.

What you'll do:

• Performs audits of claims ensuring processing 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.
• Manage the inventory of audits against standard service level agreements (SLA's); and reporting requirements.
• Complete reporting of audits completed, with decision methodology for procedural and monetary errors which are used for quality reporting and trending analysis utilizing the QA Tool.
• Responsible to communicate adjustments to Examiners as identified on pre-payment audits, and to verify adjustment is complete and accurate.
• Identify trends based on the quality reviews, identifies quality improvement opportunities and partners with training team to develop programs.
• May adjudicate high dollar claims and/or audit for accuracy logging results in the QA Tool.
• Confer with QA/Training Lead and/or Claims Supervisor 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.

You should have:

• Associates or bachelor's degree preferred
• Minimum of three (3) years of experience as a claim examiner with self-funded health care plans and processing in a TPA environment, meeting production and quality goals/ standards
• Detailed knowledge of relevant systems and proven understanding of processing principles, techniques, and guidelines.
• Ability to acquire and perform progressively more complex skills and tasks in a production environment.
• Experience with a highly automated and integrated claim adjudication system, El Dorado-Javelina preferred but not required.
• Proficient experience in MS Word, Excel, Outlook, and PowerPoint required

Flexible shifts, work from home and remote locations are available if quality and production goals are consistently met.

Salary range:

Our range for this role is $61,000 - $74,000.To determine our range, we consider as many of the following data points as are available to us: external market salary survey data, internal data in terms of comparable roles and our budget for the position. Compensation is both an art and a science (as is negotiating a salary for a new job at a new company!), so what we have posted is our good faith estimate of what we expect to pay. We encourage candidates to apply for positions that are of interest and share their desired salary. We consider that as an additional data point, along with candidate skills and qualifications as part of our process.

Location:

This role is primarily located in our Buffalo, NY and can be remote based on experience.