Claims QA Auditor Lead

Centivo Inc.

Job Overview

Location

Remote

Job Type

Full-time

Full Job Description

📋 Description

• Centivo Inc. is on a mission to revolutionize healthcare affordability and quality for the backbone of our economy – workers and their employers. We are seeking a dedicated Claims QA Auditor Lead to spearhead our Claims Quality Team, ensuring the integrity and accuracy of our claims processing. This pivotal role is instrumental in upholding our commitment to providing exceptional healthcare solutions and driving operational excellence.
• As the Claims QA Auditor Lead, you will be at the forefront of our Claims Quality Review program. Your day-to-day responsibilities will encompass the comprehensive oversight and management of the Claims Quality Assurance Team. This includes providing essential mentorship, implementing and coaching through performance improvement plans, and meticulously training auditors on job performance expectations. A significant part of your role will involve reviewing audits of claims to guarantee processing accuracy, verifying that all aspects of the audit align with standard processes and the specific Client’s summary plan description. You will also be tasked with managing the inventory of audits against established standard service level agreements (SLAs) and reporting requirements, ensuring timely and efficient workflow.
• Furthermore, you will be responsible for compiling detailed reports on completed audits, including the decision methodology for both procedural and monetary errors. These reports are crucial for quality reporting and trending analysis, leveraging advanced quality tools to identify patterns and insights. A key aspect of this role is identifying trends based on the quality reviews, proactively pinpointing opportunities for quality improvement. You will then partner closely with the training team to develop and implement targeted programs designed to address these identified areas for enhancement. In collaboration with Claims Department Leadership and the Training Lead, you will address any problematic issues that warrant immediate corrective action, ensuring swift and effective resolution.
• This role is central to maintaining and elevating the quality standards within our claims processing operations. You will be accountable for positively influencing the morale of the department by setting achievable goals and fostering a strong sense of teamwork. By actively involving team members in the design and implementation of solutions to challenges, you will cultivate an environment of continuous improvement and shared ownership. Your leadership will directly impact the efficiency, accuracy, and overall effectiveness of the Claims Quality Team, contributing significantly to Centivo's mission of delivering affordable, high-quality healthcare.
• The ideal candidate will possess a keen ability to analyze complex information, identify root causes of quality issues, and develop strategic solutions. You will act as a subject matter expert, providing guidance and support to your team and collaborating across departments to drive best practices. This position offers a unique opportunity to make a tangible impact on the healthcare landscape by ensuring that our members receive the accurate and efficient claims processing they deserve. Your contributions will be vital in building trust and delivering on Centivo's promise of better healthcare for all.
• Beyond the core responsibilities, you will also be responsible for providing essential reports to department leaders. These reports will detail inventory levels, production output, turnaround lag times, and quality results, broken down by examiner, team, and client as required. This data-driven approach ensures transparency and allows for informed decision-making at all levels of the organization. Your ability to translate complex data into actionable insights will be a cornerstone of your success in this role, enabling us to continuously refine our processes and enhance our service delivery.
• Centivo is an innovative health plan dedicated to making healthcare more affordable and accessible. We are backed by leading investors and are committed to transforming the healthcare system from the ground up. By joining our team, you will be part of a dynamic and growing organization that values resilience, uncommon approaches, and a positive, supportive culture. This is an opportunity to contribute to a meaningful mission while developing your leadership and quality assurance expertise in a fast-paced, impactful environment.

🎯 Requirements

• Minimum of three (3) years of experience in a claim examiner or quality assurance role within a health care company, consistently meeting production and quality goals/standards.
• Detailed knowledge of relevant claims processing systems and a proven understanding of processing principles, techniques, and guidelines.
• Proficiency in MS Office applications (Word, Excel, Outlook, PowerPoint) and experience with a highly automated and integrated claim adjudication system.
• Excellent verbal and written communication skills, with the ability to convey complex information clearly and concisely, and to understand and interpret complex information from others.
• Proven organizational, rational reasoning, problem-solving skills, with meticulous attention to detail necessary to operate effectively within a complex environment.

🏖️ Benefits

• Opportunity to work remotely.
• Contribute to a mission-driven company focused on making healthcare affordable and high-quality.
• Develop leadership and quality assurance expertise within a growing innovative health plan.

Skills & Technologies

Senior

Remote

Degree Required

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Centivo Inc.

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About Centivo Inc.

Centivo is a health plan administrator that partners with self-insured employers to provide affordable healthcare benefits. It builds custom networks of high-value primary care providers and specialists, emphasizing coordinated care, transparent pricing, and payment innovations like prospective bundled payments. The platform offers members digital tools for provider search, cost estimates, and care navigation, while giving employers predictable costs and data analytics to improve population health outcomes.

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