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<h3>Job Description</h3>
Job Description
Summary:
A Hospital Claims Auditor is responsible for the overall quality of claims processes as well as compliance, in accordance with outside regulations and the contractual obligations of the Health Plans and/or Hospital Clients. Research, reviews and contacts provider services for problem claims and issues, as needed. Suggests process improvements to management and is a resource of information to all staff. The Claims auditor also performs special projects and helps department manager and director as needed. They review and audit the Examiners’ adjudicated claims for accuracy and providing feedback.
Duties and Responsibilities:
· Audit daily processed claims through random selection as outlined by organizational Policies and Procedures. Utilize appropriate system-generated reports applicable to specialty claims.
· Conduct Claims Examiner training as required. Document training materials and attendees.
· Conduct in-depth research of contract issues, system-related problems, claims processing Policies and Procedures, etc., to confirm cause of trends. Recommend actions/resolutions to Senior Management.
· Work with other organizational departments
· Assist in the development of Claims Department Policies and Procedures.
· Provide backup for other auditors/trainers within the Department.
· Perform other tasks as assigned by Senior Management.
· Promote a spirit of cooperation and understanding among all personnel.
· Attend organizational meetings as required
· Adhere to organizational Policies and Procedures.
· Adhere to MedPOINT Management’s core value: Accountability, Community, Celebration, Integrity, Innovation &amp; Collaboration
Minimum Job Requirements:
· High School Diploma required.
· Three years of experience in a managed care claims adjudication setting e.g., HMO/MSO, required.
· Expertise in coding structure, ICD-10, CPT-4 and Revenue Codes, required.
· Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology and standard industry reimbursement methodologies required.
Knowledge, Skills and Abilities Required:
· Strong organizational, analytical and oral/ written communication (English) skills required.
· Proficiency in PC application skills, e.g., word processing, spreadsheets, preferred
· Experience in training development and presentation preferred
· Must be able to follow directions and also perform independently according to departmental standards.

Hospital Claims Auditor

<h3>Job Description</h3>
Job Description
Description:
Processes less complex or small standard claims to ensure accurate and timely completion. Essential Job Functions -Enters insurance claims received electronically or in written form. -Answers incoming customer calls regarding claim processing. Documents claim and associated history. -Evaluates available information to validate straightforward basic claims. Verifies policyholder information, policy effective dates, premium status and verification of claim eligibility. -Sends claim form to claimant for updating, correction or completion. -Identifies need for additional information; contacts appropriate source to obtain needed information. Verifies beneficiary or claimant information if claim is warranted. Identifies payment amount and obtains required management approvals for payment. Processes payment. -Advises claimant of status and resolution of claim. Escalates claimant concerns as appropriate. Basic Qualifications -High school diploma or G.E.D. -Zero or more years of claims experience -Experience working with insurance and/or medical terminology -Experience working with appropriate claims processing procedures and documentation Other Qualifications -Basic analytical and problem solving skills -Interpersonal skills to interact with team members -Communication skills to communicate with customers -Data entry skills -Ability to keep sensitive and confidential material private -Ability to work in a team environment Work Environment -Office environment 
Company DescriptionSelect Source International (SSI) is a distinguished staffing company with nearly 25 years of experience, renowned for delivering top-tier workforce solutions encompassing staffing, recruiting, and managed services. As a proud supplier, we bring a wealth of expertise and best-in-business differentiators to comprehensively support your diverse workforce needs. Based in Minneapolis, Minnesota, USA, SSI has established itself as a global leader, serving a broad clientele across industries with unwavering dedication and excellence. SSI is ISO 9001, 14001, and Soc2 Type2 certified, underscoring our commitment to quality and security. We have garnered numerous sustainability and supplier diversity awards, further validating our industry-leading capabilities 
<h3>Company Description</h3>
Select Source International (SSI) is a distinguished staffing company with nearly 25 years of experience, renowned for delivering top-tier workforce solutions encompassing staffing, recruiting, and managed services. As a proud supplier, we bring a wealth of expertise and best-in-business differentiators to comprehensively support your diverse workforce needs.\r\n\r\nBased in Minneapolis, Minnesota, USA, SSI has established itself as a global leader, serving a broad clientele across industries with unwavering dedication and excellence. SSI is ISO 9001, 14001, and Soc2 Type2 certified, underscoring our commitment to quality and security. We have garnered numerous sustainability and supplier diversity awards, further validating our industry-leading capabilities

Hybrid Claims Examiner

<h3>Job Description</h3>
Job DescriptionDescriptionAbout Reserv
Reserv is an insurtech creating and incubating cutting-edge AI and automation technology to bring efficiency and simplicity to claims. Founded by insurtech veterans with deep experience in SaaS and digital claims, Reserv is venture-backed by Bain Capital and Altai Ventures and began operations in May 2022. We are focused on automating highly manual tasks to tackle long-standing problems in claims and set a new standard for TPAs, insurance technology providers, and adjusters alike.
We have ambitious (but attainable!) goals and need adjusters who can work in an evolving environment. If building a leading TPA and the prospect of tackling the long-standing challenges of the claims role sounds exciting, we can't wait to meet you. 
About the role
We are seeking a skilled Litigation Claims Examiner to manage litigated files and attend trials, conferences, mediations, and arbitrations. The successful candidate will:
<ul>
<li>Investigate and gather all necessary information and documentation related to claims</li>
<li>Evaluate liability and damages</li>
<li>Negotiate and settle claims</li>
<li>Manage litigation cases related to auto claims disputes</li>
</ul>
The Litigation Claims Examiner will also be responsible for maintaining electronic files, analyzing defense counsel's performance, and regularly reporting to the Claims Manager. In addition, you will collaborate closely with our product and engineering teams to give feedback and identify technology and process improvements.
Who you are
<ul>
<li>Highly motivated and growth-oriented. You're excited by the prospect of building a tech-driven claims org.</li>
<li>Passionate adjuster who cares about the customer and their experience.</li>
<li>Empathetic. You exercise empathy and patience towards everyone you interact with. </li>
<li>Sense of urgency - at all times. That does not mean working at all hours.</li>
<li>Creative. You can find the right exit ramp (pun intended) for the resolution of the claim that is in the insured's best interest. </li>
<li>Conflict-enjoyer. Conflict does not have to be adversarial, but it HAS to be conversational. </li>
<li>Curious. You have to want to know the whole story so you can make the right decisions early and action them to a prompt resolution. </li>
<li>Anti-status quo. You don't just wish things were done differently, you action on it. </li>
<li>Communicative. (we'd love to know what this means to you)</li>
<li>And did we mention, a sense of humor. Claims are hard enough as it is. </li>
</ul>
What we need
We need you to do all the things typical to the role:
<ul>
<li>Managing legal aspects of litigated cases, including evaluation of legal process and expenses</li>
<li>Analyzing and reviewing auto insurance claims to identify areas of dispute, investigating and gathering all necessary information and documentation related to the claim, evaluating liability and damages related to the claim, and negotiating and settling claims with opposing parties or their insurance providers</li>
<li>Managing litigation cases related to auto claims disputes, attending mediations, arbitrations, and court hearings as necessary, and communicating regularly with clients, claims adjusters, attorneys, and other stakeholders</li>
<li>Collaborating with defense counsel, claims counsel, and litigation claims management for strategic planning, including developing and maintaining positive working relationships with approved defense firms and other vendors in the industry</li>
<li>Reviewing legal documents and ensuring compliance with initial suit-handling plan of action</li>
<li>Serving as corporate representative for discovery review and depositions, and appearing as Corporate Representative at depositions and trials when needed</li>
<li>Analyzing policy language and reaching appropriate coverage decisions, drafting frequent and complex coverage correspondence, and proactively managing primarily litigated claim files from inception to closure</li>
<li>Directing and controlling the activities and costs of numerous outside vendors including defense counsel and coverage counsel, experts and independent adjusters</li>
<li>Maintaining adjuster licenses and continuing education requirements</li>
</ul>
Requirements
<ul>
<li>Bachelor's degree (lack of one should not stop you from applying if you possess all the other qualifications)</li>
<li>Active insurance adjuster's license by way of a designated home state, or home state</li>
<li>10+ years of claim handling experience, with 5+ of those years handling a pending of &gt;60% in litigation</li>
<li>Commercial transportation litigation (auto, trucking, etc) is preferred but those with personal lines experience should still apply if they meet all other requirements.</li>
<li>You are not intimidated by an attorney, even if you are not one! You are the driver of the litigation strategy for any particular claim. You manage the discovery in the order and timing of events and hold attorney accountable</li>
<li>Understand transportation coverages. Understand contractual risk transfer and additional insured forms</li>
<li>You have strong medical knowledge </li>
<li>You have a sense of urgency and understanding of how to manage time-sensitive demands</li>
<li>Ability and willingness to communicate both on the phone and in written form in a prompt, courteous, and professional manner</li>
<li>Strong analytical and negotiation skills. You will conduct your own negotiations directly with opposing counsel</li>
<li>Knowledge of multiple state statutes, including good faith claim handling practices, regulations, and guidelines</li>
<li>Ability to professionally collaborate with all stakeholders in a claim</li>
<li>Willing to obtain all licenses within 60 days, including completing state required testing</li>
<li>Attention to detail, time management, and the ability to work independently in a fast-paced, remote environment</li>
<li>Curious and motivated by problem solving and questioning the status quo</li>
<li>Desire to engage in learning opportunities and continuous professional development</li>
<li>Willingness to travel for client and claims needs</li>
</ul>
Benefits
<ul>
<li>Generous health-insurance package with nationwide coverage, vision, &amp; dental</li>
<li>401(k) retirement plan with employer matching</li>
<li>Competitive PTO policy – we want our employees fresh, healthy, happy, and energized!</li>
<li>Generous family leave policy</li>
<li>Work from anywhere to facilitate your work life balance</li>
<li>Apple laptop, large second monitor, and other quality-of-life equipment you may want. Technology is something that should make your life easier, not harder!</li>
</ul>
Additionally, we will
<ul>
<li>Provide a manageable pending for you to deliver the service in a way you've always wanted and a dedicated account</li>
<li>Listen to your feedback to enhance and improve upon the long-standing challenges of an adjuster </li>
<li>Work toward reducing and eliminating all the administrative work from an adjuster role</li>
<li>Foster a culture of empathy, transparency, and empowerment in a remote-first environment</li>
</ul>
At Reserv, we value diversity in backgrounds, perspectives, and life experiences and believe that diversity in viewpoints and critical thinking drives innovation, first-principles thinking, and success. We welcome applicants from all backgrounds and encourage those from all walks of life to apply. If you believe you are a good fit for this role, we would love to hear from you!

Litigation Claims Examiner

<h3>Job Description</h3>
Job Description
Overview
Now Hiring! Insurance Claims Specialist 
Status: Non-Exempt
Schedule: Full Time
Reports to: Director of IAP

Primary Job Responsibilities: 
<ul>
<li>Process insurance-related documentation accurately and timely and consistent with program guidelines</li>
<li>Verify vendor and payment details with insurance companies</li>
<li>Process new enrollee and closure requests</li>
<li>Maintain database to accurately track and manage payments and client data</li>
<li>Interact with Case Managers, clients, insurance companies as needed</li>
<li>Maintain documentation in client charts and database of contacts with clients, Case Managers, and insurance companies</li>
<li>Ensure clients who benefit from assistance have uninterrupted coverage</li>
<li>Process premium, copay, and coinsurance payments in an accurate and timely manner</li>
<li>Actively participate in team meetings to ensure a broad understanding of program processes and facilitate process improvement</li>
<li>Actively participate in cross-training activities to facilitate understanding of departmental processes</li>
</ul>

Required Qualifications/Skills: 
<ul>
<li>Minimum 2 years’ experience in claims processing, insurance billing, benefits administration</li>
<li>Strong problem recognition and resolution skills</li>
<li>Ability to work accurately in a fast-paced environment</li>
<li>High level of proficiency with Microsoft Office software (Word, Excel)</li>
<li>Ability to work with sensitive information and maintain confidentiality</li>
<li>Ability to work effectively as part of a team and independently</li>
<li>Demonstrated ability to cultivate and maintain positive working relationships</li>
<li>Superior verbal, written, customer service and analytical skills</li>
<li>Valid Tennessee Driver’s License and automobile liability insurance</li>
</ul>

Preferred Qualifications/Skills: 
<ul>
<li>Undergraduate degree and/or some college coursework</li>
<li>Knowledge of Ryan White programs</li>
<li>Experience working with clients in HIV/AIDS social services setting </li>
<li>Knowledge of healthcare environment</li>
</ul>
Nashville CARES is an equal opportunity employer committed to providing an inclusive and welcoming environment for all members of our staff, volunteers and clients. We respect equality and inclusivity for all people and will not discriminate on the basis of race, color, gender, national origin, age, religion, creed, disability, veteran status, sexual orientation or gender identity. We respect, value and celebrate the unique attributes, characteristics and perspectives that make each person who they are.
The above information has been designed to indicate the general nature and level of work performed by an employee in this position. It is not to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications of employees assigned to this job.

Insurance Claims Specialist

<h3>Job Description</h3>
Job DescriptionThis is a profit sharing position. It is set up for a salary draw of $50k/yr. We will provide a laptop and the necessary software subscriptions. You will need a phone and reliable transportation. You will be responsible for the execution of the job from start to finish. This includes all mitigation services such as: Water, Mold, Biohazard, Contents, and Reconstruction services. You will need to know the technical aspects of these services along with the estimating and invoices. You will need to learn how to execute the jobs according to our SOP. You need to become proficient in estimating software such as: Xactimate, Estimate, and Time and Materials. This position requires that you hit quarterly performance numbers. Construction or previous experience is welcomed but not necessary.

Loss Claims Specialists

<h3>Job Description</h3>
Job DescriptionBenefits: 
<ul>
<li>Dental insurance</li>
<li>Health insurance</li>
<li>Paid time off</li>
<li>Vision insurance</li>
</ul>
 Job Description: 
<ul>
<li>The PD Claims Supervisor will oversee insurance claims departments and key personnel involved in claims processing and insurance program coverage. This role focuses on facilitating auto claims and resolving complex claims issues.</li>
</ul>
Tasks: 
<ul>
<li>Manage and supervise claims adjusters and other employees involved in claims processing.</li>
<li>Facilitate and problem-solve auto claims issues.</li>
<li>Ensure compliance with insurance program coverage and company policies.</li>
<li>Review and analyze claims for accuracy, efficiency, and resolution.</li>
<li>Provide training and professional development opportunities for team members.</li>
<li>Monitor claims processing to ensure timely handling and address any delays.</li>
<li>Maintain and update claims-related documentation.</li>
</ul>
Qualifications: 
<ul>
<li>Minimum 3-5 years of experience handling complex and severe auto claims with high exposures in Texas.</li>
<li>Must have experience handling attorney repped claims</li>
<li>Must be detail oriented and show a high level of accuracy</li>
<li>Excellent verbal and written communication skills</li>
<li>Exercise decisiveness and execution within authority</li>
<li>Ability to work independently and as a team</li>
<li>Strong problem-solving skills</li>
<li>Strong time management and organizational ability</li>
<li>Proficient with computer software</li>
<li>Experience with TX Non-Standard Auto investigating coverage and liability</li>
<li>Must hold an All-Lines Adjuster license in Texas.</li>
<li>Able to work in-office at our Claims office locations</li>
</ul>

PD Claims Supervisor

<h3>Job Description</h3>
Job DescriptionDescriptionAbout Reserv
Reserv is an insurtech creating and incubating cutting-edge AI and automation technology to bring efficiency and simplicity to claims. Founded by insurtech veterans with deep experience in SaaS and digital claims, Reserv is venture-backed by Bain Capital and Altai Ventures and began operations in May 2022. We are focused on automating highly manual tasks to tackle long-standing problems in claims and set a new standard for TPAs, insurance technology providers, and adjusters alike.
We have ambitious (but attainable!) goals and need adjusters who can work in an evolving environment. If building a leading TPA and the prospect of tackling the long-standing challenges of the claims role sounds exciting, we can't wait to meet you. 
About the role
We are seeking a skilled BI-LIT Claims Examiner to manage litigated files and attend trials, conferences, mediations, and arbitrations. The successful candidate will:
<ul>
<li>Investigate and gather all necessary information and documentation related to claims</li>
<li>Evaluate liability and damages</li>
<li>Negotiate and settle claims</li>
<li>Manage litigation cases related to auto claims disputes</li>
</ul>
The BI-LIT Claims Examiner will also be responsible for maintaining electronic files, analyzing defense counsel's performance, and regularly reporting to the Claims Manager. In addition, you will collaborate closely with our product and engineering teams to give feedback and identify technology and process improvements.
Who you are
<ul>
<li>Highly motivated and growth-oriented. You're excited by the prospect of building a tech-driven claims org.</li>
<li>Passionate adjuster who cares about the customer and their experience.</li>
<li>Empathetic. You exercise empathy and patience towards everyone you interact with. </li>
<li>Sense of urgency - at all times. That does not mean working at all hours.</li>
<li>Creative. You can find the right exit ramp (pun intended) for the resolution of the claim that is in the insured's best interest. </li>
<li>Conflict-enjoyer. Conflict does not have to be adversarial, but it HAS to be conversational. </li>
<li>Curious. You have to want to know the whole story so you can make the right decisions early and action them to a prompt resolution. </li>
<li>Anti-status quo. You don't just wish things were done differently, you action on it. </li>
<li>Communicative. (we'd love to know what this means to you)</li>
<li>And did we mention, a sense of humor. Claims are hard enough as it is. </li>
</ul>
What we need
We need you to do all the things typical to the role:
<ul>
<li>Managing legal aspects of litigated cases, including evaluation of legal process and expenses</li>
<li>Analyzing and reviewing auto insurance claims to identify areas of dispute, investigating and gathering all necessary information and documentation related to the claim, evaluating liability and damages related to the claim, and negotiating and settling claims with opposing parties or their insurance providers</li>
<li>Managing litigation cases related to auto claims disputes, attending mediations, arbitrations, and court hearings as necessary, and communicating regularly with clients, claims adjusters, attorneys, and other stakeholders</li>
<li>Collaborating with defense counsel, claims counsel, and litigation claims management for strategic planning, including developing and maintaining positive working relationships with approved defense firms and other vendors in the industry</li>
<li>Reviewing legal documents and ensuring compliance with initial suit-handling plan of action</li>
<li>Serving as corporate representative for discovery review and depositions, and appearing as Corporate Representative at depositions and trials when needed</li>
<li>Analyzing policy language and reaching appropriate coverage decisions, drafting frequent and complex coverage correspondence, and proactively managing primarily litigated claim files from inception to closure</li>
<li>Directing and controlling the activities and costs of numerous outside vendors including defense counsel and coverage counsel, experts and independent adjusters</li>
<li>Maintaining adjuster licenses and continuing education requirements</li>
</ul>
Requirements
<ul>
<li>Bachelor's degree (lack of one should not stop you from applying if you possess all the other qualifications)</li>
<li>10+ years of claim handling experience, with 5+ of those years handling a pending of &gt;60% in litigation</li>
<li>Transportation litigation (rideshare, auto, trucking, etc) is preferred but those with personal lines experience should still apply if they meet all other requirements.</li>
<li>You are not intimidated by an attorney, even if you are not one! You are the driver of the litigation strategy for any particular claim. You manage the discovery in the order and timing of events and hold attorney accountable</li>
<li>Understand transportation coverages. Understand contractual risk transfer and additional insured forms</li>
<li>You have strong medical knowledge </li>
<li>You have a sense of urgency and understanding of how to manage time-sensitive demands</li>
<li>Ability and willingness to communicate both on the phone and in written form in a prompt, courteous, and professional manner</li>
<li>Strong analytical and negotiation skills. You will conduct your own negotiations directly with opposing counsel</li>
<li>Knowledge of multiple state statutes, including good faith claim handling practices, regulations, and guidelines</li>
<li>Ability to professionally collaborate with all stakeholders in a claim</li>
<li>Have active adjuster license(s) and be willing to obtain all licenses within 45 days, including completing state required testing</li>
<li>Attention to detail, time management, and the ability to work independently in a fast-paced, remote environment</li>
<li>Curious and motivated by problem solving and questioning the status quo</li>
<li>Desire to engage in learning opportunities and continuous professional development</li>
<li>Willingness to travel for client and claims needs</li>
</ul>
Benefits
<ul>
<li>Generous health-insurance package with nationwide coverage, vision, &amp; dental</li>
<li>401(k) retirement plan with employer matching</li>
<li>Competitive PTO policy – we want our employees fresh, healthy, happy, and energized!</li>
<li>Generous family leave policy</li>
<li>Work from anywhere to facilitate your work life balance</li>
<li>Apple laptop, large second monitor, and other quality-of-life equipment you may want. Technology is something that should make your life easier, not harder!</li>
</ul>
Additionally, we will
<ul>
<li>Provide a manageable pending for you to deliver the service in a way you've always wanted and a dedicated account</li>
<li>Listen to your feedback to enhance and improve upon the long-standing challenges of an adjuster </li>
<li>Work toward reducing and eliminating all the administrative work from an adjuster role</li>
<li>Foster a culture of empathy, transparency, and empowerment in a remote-first environment</li>
</ul>
At Reserv, we value diversity in backgrounds, perspectives, and life experiences and believe that diversity in viewpoints and critical thinking drives innovation, first-principles thinking, and success. We welcome applicants from all backgrounds and encourage those from all walks of life to apply. If you believe you are a good fit for this role, we would love to hear from you!

<h3>Job Description</h3>
Job Description
Description of services: 
Audit a portion, as mutually agreed between the parties, of the combined financially stratified/attribute claim sample of medical and dental claims processed by medical care administrators. During the identified audit period (i.e., audits performed in 2024 will review claims processed through January 1, 2023 - through December 31, 2023, etc.). The audits will be conducted virtually with each administrator.
 
Tasks, Activities and Deliverables
The claims audit elements include review and validation:
The claimant was eligible for benefits on the date(s) of service based on data in the administrator's eligibility files, 
<ul>
<li> The provider's network participation was correctly determined based on the date of service, </li>
<li> Claims requiring utilization review approval were reviewed and processed in accordance with utilization review decisions, </li>
<li> Deductibles, coinsurance and other appropriate cost-sharing features of the benefit plan were considered and correctly applied, </li>
<li> The claim data was entered into the claim system correctly, and whether a paper claim was keyed or scanned, </li>
<li> Appropriate checks were made to ensure that there was no other coverage available to the claimant or, if there was other coverage, payments were coordinated correctly, </li>
<li> The "reasonable and customary" or provider discount features of the plan were correctly applied, including unbundling for physician services, </li>
<li> Appropriate edits were made to ensure that the claim was not paid twice, </li>
<li> The procedure(s) billed and paid were, in fact, covered by the plan and do not appear to be fraudulent billings by the provider, </li>
<li> The mathematics and computations were correct, </li>
<li> Any pre-authorization limits were appropriately applied, </li>
<li> The paper claim form was completed appropriately and signed by the appropriate parties, </li>
<li> The administrator adhered to its own internal policies and procedures when processing the claim, </li>
<li> Appropriate approvals were applied to high dollar claims (pre- and post-payment), and</li>
<li>Sufficient documentation was included in the file to support the adjudication of the claim.</li>
</ul>
Education and Experience
<ul>
<li>Bachelor's degree in accounting, finance, or a related field such as health information management.</li>
<li>At least three years of experience as a claims auditor or similar role in the health care industry. </li>
</ul>
Skills
<ul>
<li>Strong analytical and problem-solving skills</li>
<li>Excellent attention to detail</li>
<li>Ability to communicate complex information effectively and clearly</li>
<li>Good understanding of insurance policies and regulations</li>
<li>Proficiency in using computer software such as Microsoft Office Suite</li>
</ul>
Personal Attributes
<ul>
<li>Ability to work independently and in a team environment.</li>
<li>High level of integrity and ethical behavior.</li>
<li>Strong organizational and time-management skills.</li>
<li>Flexible and adaptable to change.</li>
</ul>

Claims Quality Auditor

<h3>Job Description</h3>
Job Description
We exist for workers and their employers -- who are the backbone of our economy.&nbsp; 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.
Summary of role:
The Claims QA Auditor is primarily responsible for pre-payment, post-payment, and adjudication audits of claims across multiple employer groups and products, including complex high-dollar claims. This includes handling all aspects of the Claims Quality Review program, establishing processing standards, responding to quality issues, assisting in implementing performance improvement plans, providing data for performance guarantee service level agreements, and assisting with ensuring reports are completed and distributed timely.
Responsibilities Include:
<ul>
<li>
Perform auditing of claims, ensuring processing, payment, and financial accuracy by verifying all aspects of the claim have been handled correctly and according to both standard process and the client’s summary plan description.
</li>
<li>
Completes reporting of audits finalized with decision methodology for procedural and monetary errors, which are used for quality reporting and trending analysis utilizing QA tools.
</li>
<li>
Responsible to communicate corrections and adjustments to Examiners as identified on pre-payment audits, including high dollar claims, and to verify corrections and adjustments are complete and accurate.
</li>
<li>
Identify and escalate trends based on the quality reviews.
</li>
<li>
Confer with Claims QA Lead, Claims Supervisors, Claim Managers, and/or Training Lead on any problematic issues warranting immediate corrective action.
</li>
<li>
May investigate and research issues as required to create or improve standard processing guidelines and may participate in projects as a subject matter expert as needed.
</li>
<li>
Perform any other additional tasks as necessary, including processing of claims, creating policies, training, and/or mentoring examiners through quality improvement plans.
</li>
</ul>
Qualifications:
Required Skills and Abilities:
<ul>
<li>
Prior experience with a highly automated and integrated claims processing system, El Dorado-Javelina or Health Rules Payer (HRP) preferred.
</li>
<li>
Detailed knowledge of relevant systems and proven understanding of processing principles, techniques, and guidelines.
</li>
<li>
Strong analytical, organizational, and interpersonal skills, with the ability to communicate effectively with others.
</li>
<li>
Attention to detail, organized, quality and productivity driven.
</li>
</ul>
Education and Experience:
<ul>
<li>
High School diploma or GED required.
</li>
<li>
Associate or bachelor’s degree preferred.
</li>
<li>
Minimum of three (3) years of experience as a claim examiner and/or auditor with self-funded health care plans and processing in a TPA environment, meeting production and quality goals/ standards.
</li>
<li>
Proficient experience in MS Word, Excel, Outlook, and PowerPoint required.
</li>
</ul>
Preferred Qualifications:
<ul>
<li>
Ability to acquire and perform progressively more complex skills and tasks in a production environment.
</li>
<li>
Ability to work under limited supervision and provide guidance and coaching to others.
</li>
<li>
Excellent coaching skills and ability to mentor others towards quality improvement.
</li>
</ul>
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.
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 &amp; Co.
Compensation Range: $55K - $60K

Claims QA Auditor

<h3>Job Description</h3>
Job Description

Claims Examiner II
Location: Birmingham, AL
Job Description
The Claims Examiner II will administer all claims adjudication processes in accordance with contractual agreements along with VIVA HEALTH guidelines. This position will assist with additional duties such as reports and following up with departments on routed claims. Must be available to work during the core hours of operation, 8am to 5pm Monday through Friday, and overtime as required.
Key Responsibilities
<ul>
<li>Adjudicate claims submitted by providers and members assigned via claims workflow.</li>
<li>Reviewing claims for required information, pending claims when necessary, maintaining a follow-up system, and updating and releasing pending claims when indicated.</li>
<li>Correctly match authorizations to ensure claims are processing appropriately based on established guidelines.</li>
<li>Work with internal departments to resolve issues preventing claims from processing or enhancing processing capabilities.</li>
<li>Meet and maintain performance and quality measurements as required by the department to meet regulatory compliance standards.</li>
</ul>
REQUIRED:
<ul>
<li>At least 1–2 years of experience with claims processing</li>
<li>2 years of college or equivalent claims adjudication experience</li>
<li>Ability to thrive in a production environment where quality and quantity are highly measured, including recognizing and correcting quality errors</li>
<li>Demonstrate excellent customer service skills through written and verbal communication</li>
<li>Organized, detail oriented, and skilled at prioritizing and multitasking</li>
<li>Ability to work in a team environment, remain flexible to changes, and recognize responsibilities, actively participate with others to accomplish assignments and achieve desired goals</li>
<li>Knowledge of medical terminology, ICD, CPT, and HPCS</li>
<li>Basic computer skills including Microsoft Word, Excel, and Outlook</li>
<li>Understanding of Claims Payment System in order to process claims, prepare reports and correspondence</li>
</ul>
PREFERRED:
<ul>
<li>Professional and/or hospital claims adjudication experience, preferably in the healthcare/medical field</li>
<li>CRT data entry experience</li>
</ul>

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