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Date Added: Sat 18/07/2020

Claims Auditor

Tampa, Florida, US
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Company: CENTENE

Job Type: Permanent, FullTime

Claims Auditor


Position Purpose: Claims Auditor is responsible for the quality audit of a variety of specific processes within the operations services for Claims to ensure quality service goals and standards are met and/or identify areas where improvement can be achieved. Provides audit feedback regarding the exceptions, patterns and trends to management.

- Performs routine and moderately complex audits to identify trends, issues, and exceptions to the established claims adjudication requirements. Reports to management when quality standards impact the business unit, company, affiliates and/or clients and customers.

- Proactively identifies performance trends/patterns of audits to management, and makes recommendations to improve quality, workflow processes, policies and procedures.

- Provides timely review and completion on all contested claims.

- Researches claim processing problems and errors to determine their origin and provides appropriate feedback to examiners, trainers and management.

- Manually enters audit data into the database to develop reports based on the audit findings.

- Provides coaching and feedback to examiners and management on prepayment and post payment findings and trends.

- Provides recommendations for additional training or updates that will help prevent further errors to enhance service and productivity within Health Net.

- Maintains a comprehensive working knowledge of Policies, Procedures, Compliance Regulations, Schedule of Benefits and turn around times across all product lines.

- Participates in specialized training within departments.

- Monitors daily assignments and prioritizes aged audits to ensure all audits are completed timely per regulatory and department guidelines.

- Performs other related duties as assigned.

Education/Experience: High School Diploma required. Minimum one year relevant experience . In-depth experience in Health Care Claims, Contracts, Benefit Application, Coordination of Benefits

Claims Operations



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