Senior Quality Auditor

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.

Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT

Applicants for this role have the flexibility to work remotely within the continental United States. To support the needs of the business, preferred schedule is based on Central Standard Time zone or Eastern Standard Time zone.

• 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.

Education/Experience: High School Diploma or equivalent; some college coursework preferred.

It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act