Senior Quality Auditor

Centene Corp.; Northern (KY); Hybrid; USD 32,000 - 55,000; Full time

Job summary

Centene Corp. seeks a Senior Quality Auditor to improve claims quality and compliance across the automated processing environment. This remote role focuses on auditing pre and post payment claims, researching discrepancies, and supporting cost-saving initiatives.

The ideal candidate has strong data management experience, will maintain department statistics for regulators and certification bodies, and communicate findings to management to drive process improvements.

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.

Responsibilities

• Reviews and supports the claims process for medical review and cost saving initiatives.
• Maintains department statistics, as necessary, 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 in order 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.

Education

High School Diploma or equivalent

Job description

## Senior Quality AuditorApply: Remote-MO: Full time: Posted Yesterday: 1658226**Position Purpose:** 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, documenting and reporting audit results, and researching claims and enrollment discrepancies as they are related to provider data. In addition this position may manage a variety of other PDM related projects that typically require advanced knowledge and skills of the provider files and their relation to the claims processing systems.**Key Details:** Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPTApplicants for this role have the flexibility to work remotely within the continental United States. To support the needs of the business, preferred schedule is based on Central Standard Time zone or Eastern Standard Time zone.* Reviews and supports the claims process for medical review and cost saving initiatives.* Maintains department statistics, as necessary, 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 in order 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.**Education/Experience:** 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 environmentPay Range: $23.23 - $39.61 per hour