Submission for the position: Senior Quality Auditor -- Remote Available - (Job Number: 1251432)
https://centene.taleo.net/careersection/jobdetail.ftl?job=1251432&lang=en
Senior Quality Auditor -- Remote Available
You could be the one who changes everything for our 25 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, multi-national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
Position Purpose: 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. In addition this position may manage a variety of other PDM related projects that typically require advanced knowledge and skills of the provider files and their relation to the claims processing systems.
• 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 reviewing reports to target errors and provide coaching’s to associates for retraining.
• Review pharmacy related grievances and complaints and other issues received in the share mailbox
• 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 Pharmacy Ops. department regarding results of audited and/or reviewed reports in order to improve errors  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.
• Assists with auditing staff and vendor partners in accordance with established CMS guidelines
• Partner with business groups to identify and resolve errors in data and reporting, and present findings and recommendations for improvement to management.
• Assist with the administration of audit processes and tools related to prior authorizations, appeals, quality improvement, star measurement reviews, inter-rater reliability and data entry.
Our Comprehensive Benefits Package:
• Flexible work solutions including remote options, hybrid work schedules and dress flexibility
• Competitive pay
• Paid Time Off including paid holidays
• Health insurance coverage for you and dependents
• 401(k) and stock purchase plans
• Tuition reimbursement and best-in-class training and development
Education/Experience: 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
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.
Quality Assurance
USA-Florida-Tampa
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Schedule: Full-time Location(s): USA-Florida-Tampa