Lead Claims Quality Auditor
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.
The Lead Claims Quality Auditor is primarily responsible for overseeing the daily operation of the Claims Quality Team, including handling all aspects of the Claims’ Quality Review program, implementing and adhering to processing standards, responding to quality issues, partnering with other operational areas to implement performance improvement plans, and ensuring reports are complete and distributed timely. This includes being responsible for providing reports to department leaders on inventory, production, turn-around lag and quality results at an examiner, team, and client level, as required.
This individual will be accountable for positively influencing the morale of the department, including setting achievable goals, fostering teamwork by involving team members in the design/implementation of solutions to problems.
Responsibilities Include:
Oversight and management of the Claims Quality Assurance Team, including mentoring the team, implementing and coaching through performance improvement plans, and training auditors on job performance expectations.
Reviewing audits of claims, ensuring processing accuracy by verifying all aspects of the audit have been handled correctly and according to both standard processes and the Client’s summary plan description.
Managing the inventory of audits against standard service level agreements (SLA’s) and reporting requirements.
Compiling reporting of audits completed, with decision methodology for procedural and monetary errors which are used for quality reporting and trending analysis utilizing quality tools.
Identifying trends based on the quality reviews, identifies quality improvement opportunities and partners with training team to develop programs.
Partnering with Claims Department Leadership and Training Lead on any problematic issues warranting immediate corrective action.
Qualifications:
Required Skills and Abilities:
Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
Must possess proven organizational, rational reasoning, ability to examine information, and problem-solving skills, with attention to detail necessary to act within complex environment.
Ability to comprehend and produce grammatically accurate, error-free business correspondence required.
Ability to appropriately identify urgent situations and follow the appropriate protocol.
Requires the ability to plan, manage multiple priorities, and deliver complete, accurate, and timely results in a fast-paced office environment.
Ability to work under limited supervision and provide guidance and coaching to others.
Excellent coaching skills and ability to mentor others towards quality improvement
Proficiency in MS Office applications required.
Education and Experience:
High School diploma or GED required, Associate or Bachelor’s degree preferred.
Minimum of three (3) years of experience in a claim examiner or quality assurance role with a health care company, meeting production and quality goals/ standards.
Detailed knowledge of relevant systems and proven understanding of processing principles, techniques, and guidelines.
Ability to acquire and perform progressively more complex skills and tasks in a production environment.
Proficient experience in MS Word, Excel, Outlook, and PowerPoint.
Experience with a highly automated and integrated claim adjudication system.
Work Location:
Candidates located within commuting distance of our Buffalo office will be considered for both in-person and hybrid roles. All other applicants will be considered for remote positions.
Leadership Skills & Behaviors:
Strategic Thinking– Knack for sorting through clutter to find the best route, often by pulling up from the current complexity to identify patterns that guide future direction and allow one to narrow the options and articulate the options from which others can work backward.
Business Acumen – A keenness and quickness in understanding and dealing with a business situation (risks and opportunities) in a manner that is likely to lead to a good outcome. Critical to this is an ability to think beyond their own function.
Systems/Analytical Thinking – Demonstrates the ability to think fluidly and integrate information. Able to anticipate non-linear and non-obvious relationships. Often includes an ability to think holistically/conceptually – very powerful when accompanied by ability to communicate & clarify tactically.
Flexibility/Working through Ambiguity – Tendency to be energized by new experiences/perspectives that test assumptions and thinking. Considers different points of view, sometimes with fragmented information, to arrive at practical, effective, actionable next steps.
Communicate – Managers discuss the company’s vision and strategies, the department’s direction and goals, and in times of crisis, what we know and don’t know to make sure team members know what they need to know.
Clarify – As managers, it’s up to us to clarify what good looks like. What do we expect? What do our clients, customers or colleagues need? If our teams are not performing as expected, managers must clarify expectations and ensure understanding.
Coach – Managers provide recognition and feedback; help team members find solutions to challenges; amplify good and filter weaker aspects of organizational culture and the work as they coach employees in their day-to-day performance and their growth and career development.
Connect – Managers help our teams see their collective purpose and how their work connects to the greater whole. We connect people within our company and network.
Customize – As managers, we need to understand what makes each team member unique, and then customize, tailor and adapt how we support them.
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.