Claim Auditor

A Claims Auditor at Centivo is responsible for conducting comprehensive audits of claims to ensure their processing accuracy. This role involves performing pre and post-payment audits of various claims, particularly those that are complex and high dollar. The position requires you to complete thorough reporting on audits conducted, addressing any procedural and monetary errors identified. Additionally, you'll collaborate with other departments to implement quality improvement initiatives and mentor colleagues on best practices.

To qualify for the Claims Auditor role at Centivo, candidates should have a minimum of three years' experience as a claim examiner in a self-funded healthcare plan setting, preferably in a TPA environment. A high school diploma or GED is required, while an associate's or bachelor’s degree is preferred. Knowledge of claims processing principles, analytical skills, and proficiency in tools like MS Word and Excel are also essential, along with strong organizational skills and attention to detail.

Essential skills for a Claims Auditor at Centivo include strong analytical abilities, attention to detail, and excellent interpersonal communication skills. Additionally, proficiency in using automated claim adjudication systems, experience in a production environment, and the capability to guide and mentor others towards quality improvements are all crucial. Being organized and focused on productivity is key to succeeding in this role.

The work environment for a Claims Auditor at Centivo is dynamic and collaborative. Based in our downtown Buffalo office, you'll have the opportunity to work within a team that is passionate about improving healthcare. There’s also a flexible work-from-home option, allowing for a balance between office collaboration and personal work time. Overall, Centivo encourages a culture of innovation and quality.

Centivo values employee development and offers various opportunities for career growth for Claims Auditors. With an emphasis on mentoring and leadership, you'll have the chance to enhance your skills through training programs and continued professional education. Additionally, you'll be part of projects that can expand your expertise and connect you with other professionals in the industry.

When discussing your experience with claims processing, focus on the specific roles you've held and the types of claims you've worked on. Highlight your familiarity with both pre and post-payment audits and any experience with high dollar claims. If applicable, mention any systems you've used, such as automated adjudication systems, and be sure to describe how you've met quality standards and production goals in your previous roles.

To ensure accuracy in your audits, explain your systematic approach. Discuss the importance of verifying every detail of a claim against its documentation and processing standards. Mention any tools or methodologies you employ, like trend analysis from previous audit results, to maintain accuracy and identify patterns of error that might need addressing.

Discuss your proactive measures for improving claims processing quality, such as identifying trends from audits and collaborating with training teams to develop improvement programs. Highlight your analytical skills in finding root causes of errors and how you've previously implemented successful strategies to enhance the standard processing guidelines.

When handling a disagreement with a colleague, emphasize your commitment to open communication and collaboration. Describe how you would approach the situation calmly, seeking to understand their perspective while presenting your own. Mention the importance of relying on established policies and procedures to guide conflict resolution in a professional manner.

In answering this question, recount a specific situation where you discovered an issue that had a notable impact. Illustrate how you took the initiative to address the problem promptly, the steps you took to communicate the issue to your team, and what solutions or changes you proposed and implemented to prevent it from recurring.

Discuss the specific tools and software that are relevant to claims auditing. If you have experience with systems like El Dorado-Javelina, be sure to mention that. Talk about how you utilize Excel for reporting and analysis, and any experience with QA tools for tracking audit results. Highlighting proficiency in various tools demonstrates your readiness for the role.

When tackling the question of workload prioritization, explain your strategy for managing multiple audits concurrently. You could describe how you assess the urgency and complexity of each claim, allocate time accordingly, and use organizational tools to stay on track. Mention any past experiences where you successfully navigated busy periods without compromising quality.

To convey why you're a great fit for the Claims Auditor role at Centivo, highlight your relevant experience in claims processing, your analytical and problem-solving skills, and your dedication to quality improvement. Mention your familiarity with self-funded healthcare plans and how your professional values align with Centivo's mission to provide affordable healthcare.

Description of regular methods for staying informed about changes in healthcare regulations is essential. This could include attending relevant industry webinars, subscribing to healthcare publications, participating in forums or professional networks, and enrolling in training sessions. Highlight your proactive approach to learning, which reflects your commitment to maintaining high performance in your role.

In discussing your mentoring approach, emphasize your belief in guiding colleagues through constructive feedback and tailored training. Share specific examples of how you have effectively supported team members in enhancing their skills, fostering a culture of open communication, and focusing on quality outcomes. Highlight the mutual benefits of this process for both yourself and your mentees.