[Hiring] Senior Quality Auditor @Centene Corporation

Role Description

Develops and implements effective business solutions through research, audit, and analysis of data and/or business processes. Audits and validates routine pre and post payment claims to determine correct adjudication as well as compliance with corporate policies and procedures, and other applicable regulatory guidelines.

• Responsible for auditing provider data loaded into the claims processing systems.
• Documents and reports audit results.
• Researches claims and enrollment discrepancies related to provider data.
• May manage a variety of other PDM related projects requiring advanced knowledge of provider files and their relation to claims processing systems.
• Reviews and supports the claims process for medical review and cost saving initiatives.
• Maintains department statistics for quality improvement indicators, regulatory agencies, and certification bodies.
• Performs routine and moderately complex audits on medical review claims to identify exceptions to established claims adjudication requirements.
• Researches issues from reviewed claims to determine origin and appropriate resolutions.
• Summarizes findings and recommendations in reports for feedback, and distributes to management.
• Communicates with claims department regarding results of audited and/or reviewed claims to improve claims processing and resolutions.
• Provides qualified data to incorporate into training programs, policies, and procedures.
• Maintains current working knowledge of Health Net products, policies and procedures, contract and benefit plan coding, as well as health insurance industry and regulation and certification standards.

Qualifications

• High School Diploma or equivalent; some college coursework preferred.
• Four years general data management experience in an automated claims processing, claims research, or provider maintenance environment.

Requirements

• Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future.
• Applicants have the flexibility to work remotely within the continental United States.
• Preferred schedule is based on Central Standard Time zone or Eastern Standard Time zone.

Benefits

• Competitive pay.
• Health insurance.
• 401K and stock purchase plans.
• Tuition reimbursement.
• Paid time off plus holidays.
• Flexible approach to work with remote, hybrid, field, or office work schedules.