Quality Auditor
Posted on: 15 Jan 2021
Rancho Cordova, CA
Job Description
Position Purpose:
* 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, documents and reports audit results; researches claims and enrollment discrepancies as they are related to provider data.
* Researches issues from claims reviewed to determine origin and appropriate resolutions.
* Summarizes findings and recommendations in reports for feedback, and distribution to management.
* Performs routine and moderately complex audits on medical review claims to identify exceptions to established claims adjudication requirement.
* Maintains department statistics as necessary for quality improvement indicators, regulatory agencies and certification bodies.
* Provides qualified data for incorporation into training programs, policies and procedures.
* Participates in communication with claims department regarding results of claims audited and/or reviewed, in order to improve claims processing and resolutions.
* Maintains current working knowledge of Health Net products, policies and procedures, contract and benefit plan coding as well as health insurance industry and regulatory and certification standards.
Education/Experience:
High School diploma or equivalent. Three years in an automated claims processing, claims research or provider maintenance environment. One year in claims audit or provider data management analytical capacity.
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
Centene
St Louis, MO
Centene Corporation operates as a diversified and multi-national healthcare enterprise that provides programs and services to under-insured and uninsured individuals in the United States. The company’s Managed Care segment offers health plan coverage to individuals through government subsidized programs, including Medicaid, the State children’s health insurance program, long-term services and support, foster care, and medicare-medicaid plans, which covers dually eligible individuals, as well as aged, blind, or disabled programs. Its health plans include primary and specialty physician care, inpatient and outpatient hospital care, emergency and urgent care, prenatal care, laboratory and X-ray, home-based primary care, transportation assistance, vision care, dental care, telehealth, immunization, specialty pharmacy, therapy, social work, nurse advisory, and care coordination services, as well as prescriptions, limited over-the-counter drugs, medical equipment, and behavioral health and abuse services.
This segment also offers various individual, small group, and large group commercial healthcare products to employers and directly to members in the Managed Care segment.Its Specialty Services segment provides pharmacy benefits management services; health, triage, wellness, and disease management services; and vision and dental, and management services, as well as care management software that automate the clinical, administrative, and technical components of care management programs. This segment offers its services and products to state programs, correctional facilities, healthcare organizations, employer groups, and other commercial organizations. The company provides its services through primary and specialty care physicians, hospitals, and ancillary providers. Centene Corporation was founded in 1984 and is headquartered in St. Louis, Missouri.
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IndustryHealthcare
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No. of Employees47, 300
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Website
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Jobs Posted349
