You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
Position Purpose:
Independently performs peer reviews of Claims Audit staff and conducts department training. Monitors, tracks, and gives direction/feedback to Claims Audit Specialists regarding completion and performance of their audit tasks and responsibilities. Controls and maintains training materials and policies and procedure. Acts as an Audit Subject Matter Expert (SME) for all audit questions/issues.
- Serves as a mentor for all Claims Quality Auditors and provides real-time feedback for the job function.
- Serves as a SME and Lead Auditor.
- Performs peer reviews of audit staff and reviews scores with supervisor/manager and recommends process improvement as needed.
- Works with management to maintain a well trained work force in the department in order to ensure a high quality control program.
- Assists in developing goals for auditors.
- Works with supervisor to manage the "Individual Training Plans" for each auditor.
- Researches and proposes solutions for escalated issues in a clear and concise manner.
- Assists with developing and maintaining departmental policies and procedures including desk top procedures.
- Leads in developing training materials for the department and facilitates training as needed.
- Analyzes errors and performs root cause analysis in order to determine appropriate classification.
- Builds and maintains positive business relationships with business partners.
- Conducts claim audits in a lead role for internal and external entities.
- Participates on conference calls with supervisors/managers to provide audit findings and/or mediate issues.
- Communicates audit results in a structured format.
- Assists with identification and communication of process improvement opportunities across operation area's based on quality reviews.
- Performs additional duties as assigned. i.e.
- Release high dollar claim audits & distribute workload.
- Performs other duties as assigned.
- Complies with all policies and standards.
Education/Experience: A Bachelor's Degree in a related field preferred. 5+ years of experience in a healthcare organization required. 3+ years of experience in understanding claims life cycle and interpreting contracts related to claims processing and system configuration. 2+ years of experience in a Sr. Claims Auditor role in a healthcare organization preferred. License/Certification: Preferred Certified Medical Coder.
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
