Claims Adjustor

Define Ventures; United States; Remote; USD 55,000 - 75,000; Full time

Job summary

Centivo is seeking a Claims Adjustor to join our team remotely in the United States. You will adjudicate and process healthcare claims for self-funded employer groups, reviewing edits and ensuring benefits align with SPD and client funds.

Responsibilities include routing complex claims to Plan Build/System Configuration or Provider Maintenance teams, meeting production and quality goals, and contributing to process improvements.

Qualifications

• Prior experience with a highly automated and integrated claims processing system.
• Experience working with HealthRules Payer preferred.
• Knowledgeable about healthcare claims, medical coding, and rules applicable to Benefit Plans.
• Strong critical thinking skills and willingness to make independent decisions with little supervision.
• Excellent oral and written communication skills.
• Proven ability to work in a fast-paced environment, managing multiple issues with pressure of production schedules and deadlines.
• Proven ability to work independently for majority of day.
• Ability to learn new proprietary computer systems.
• High School diploma or GED required.

Responsibilities

• Adjudicating claims in assigned work queues based on Centivo’s policies and procedures and SPD terms.
• Diligently reviewing system-generated edits before releasing claims to ensure benefits are applied correctly.
• Routing claims to Plan Build/System Configuration Team for resolution when issues arise.
• Routing undecided edits to Provider Maintenance and Pricing teams for resolution.
• Denying claims for missing information and communicating needs to participants or providers.
• Maintaining daily, weekly, and monthly production levels per department policies.
• Participating in quality improvement efforts and suggesting process changes.
• Meeting production and quality goals under moderate supervision.
• Supporting higher-responsibility tasks and mentoring less experienced teammates.

Skills

Critical thinking

Communication skills

Independent work

Fast-paced environment

Microsoft Office proficiency

Education

High School diploma or GED

Tools

HealthRules Payer

Microsoft Office

Job description

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 looking for Claims Adjustors to join our team!

Training is paid and will begin in October 2026 with specific dates to be announced soon.

As a Claims Adjustor, you will manage and process healthcare claims for our self-funded employer groups. Health care providers treat patients, then file medical claims to receive payment from the patient’s Benefit Plan. Claim Adjustors review and assess the claims, adjudicating payment to the provider on behalf of the Plan if a claim is covered by the patient’s Benefit Plan. Claims Adjustors are responsible for working closely with the Claims Supervisor, Account Managers, System Configuration, and Quality Assurance Team in ensuring that claims received by Centivo are adjudicated in a timely manner and accurately. Claims Team roles are based on skill level and increased responsibilities.

What you’ll do:

• 
  

  Adjudicating claims in assigned work queues based on Centivo’s written Policies and Procedures and the terms of the Summary Plan Documents (SPD’s) for Centivo’s clients.

  
  


• 
  

  Diligently reviewing all system-generated edits which have been applied to claims in the Claims Adjustor’s assigned queues prior to releasing the claims to ensure benefits are being applied per the client’s SPD and client funds are being appropriately managed.

  
  


• 
  

  When the Claims Adjustor believes there may be an issue or inconsistency in the interpretation of a Plan as the system is applying benefits, immediately route the claim to the Plan Build/System Configuration Team for resolution.

  
  


• 
  

  When the Claims Adjustor is unable to resolve an edit based on the provider selection, the pricing and/or usual and customary discrepancies, immediately route the claim to the Provider Maintenance and/or Pricing teams for resolution.

  
  


• 
  

  When the Claims Adjustor is unable to resolve an edit based on the information included with or attached to a claim, appropriately deny the claim for additional information, and generate correspondence to the participant or provider concisely explaining data needs. When such additional data is received, reopen the denied claim, and re-adjudicate based on the information.

  
  


• 
  

  Maintain daily, weekly, and monthly required production levels documented in Claims Department Policies and Procedures.

  
  


• 
  

  Participation in Departmental quality improvement efforts and bring forward process improvement suggestions that will improve efficiencies; question a process or policy that creates additional steps or work on the Claims Adjustor and suggest an alternative solution.

  
  


• 
  

  Processes claims in accordance with established policies and procedures, contacting providers as needed, completing tasks under moderate supervision. Responsible for meeting the production and quality goals determined by the department leadership.

  
  


• 
  

  Increased responsibilities, which may include assisting and mentoring less experienced team members, participating in various initiatives or projects within the Claims Delivery Team, documenting processes, performing advanced tasks, supporting high-dollar reviews, and overpayments/refunds.

  
  

You should have:

• 
  

  Prior experience with a highly automated and integrated claims processing system.

  
  


• 
  

  Experience working with HealthRules Payer preferred

  
  


• 
  

  Knowledgeable about healthcare claims, medical coding, and rules applicable to Benefit Plans.

  
  


• 
  

  Strong critical thinking skills and willingness to make independent decisions with little supervision.

  
  


• 
  

  Excellent oral and written communication skills.

  
  


• 
  

  Proven ability to work in a fast-paced environment, managing multiple issues with pressure of production schedules and deadlines.

  
  


• 
  

  Proven ability to work independently for majority of day.

  
  


• 
  

  Proficiency in Microsoft Office applications and other web-based software applications.

  
  


• 
  

  Ability to learn new proprietary computer systems.

  
  


• 
  

  High School diploma or GED required

  
  

Location:

• 
  

  Remote

  
  


• 
  

  Must be available during standard working hours and willing to work overtime as business needs require.

  
  

Note: A knowledge assessment may be required during the interview process

Centivo Values:

• 
  

  Resilient – This is wicked hard. There is no easy button for healthcare affordability. Luckily, the mission makes it worth it and sustains us when things are tough. Being resilient ensures we don’t give up.

  
  


• 
  

  Uncommon - The status quo stinks so we had to go out and build something better. We know the healthcare system. It isn't working for members, employers, and providers. So we're building it from scratch, from the ground up. Our focus is on making things better for them while also improving clinical results - which is bold and uncommon.

  
  


• 
  

  Positive – We care about each other. It takes energy to do hard stuff, build something better and to be resilient and unconventional while doing it. Because of that, we make sure we give kudos freely and feedback with care. When our tank gets low, a team member is there to be a source of new energy. We celebrate together. We are supportive, generous, humble, and positive.

  
  

Who we are:

Centivo is an innovative health plan for self-funded employers on a mission to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills. Anchored around a primary care based ACO model, Centivo saves employers 15 to 30 percent compared to traditional insurance carriers. Employees also realize significant savings through our free primary care (including virtual), predictable copay and no-deductible benefit plan design. Centivo works with employers ranging in size from 51 employees to Fortune 500 companies. For more information, visit centivo.com.

Headquartered in Buffalo, NY with offices in New York City and Buffalo, Centivo is backed by leading healthcare and technology investors, including a recent round of investment from Morgan Health, a business unit of JPMorgan Chase & Co.