Senior Quality Auditor

March 4

🌵 Arizona – Remote

Although this job is listed in Arizona, this company may be open to hiring remote in other states.

🏄 California – Remote

Although this job is listed in California, this company may be open to hiring remote in other states.

+1 more states

🌵 Arizona – Remote 🏄 California – Remote 🌲 Oregon – Remote

💵 $22 - $38 / hour

⏰ Full Time

🟠 Senior

🔎 Auditor

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Centene Corporation

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Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

Contracting • Network Development • Managed Care

10,000+ employees

Founded 1984

⚕️ Healthcare Insurance

🤝 Non-profit

🌍 Social Impact

📋 Description

• 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. • 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.

🎯 Requirements

• 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

🏖️ Benefits

• competitive pay • health insurance • 401K and stock purchase plans • tuition reimbursement • paid time off plus holidays • flexible approach to work with remote, hybrid, field or office work schedules