Lead Claims Quality Auditor

Lead Claims Quality Auditor We exist for workers and their employers -- who are the backbone of our economy.  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. The Lead Claims Quality Auditor is primarily responsible for overseeing the daily operation of the Claims Quality Team, including handling all aspects of the Claims’ Quality Review program, implementing and adhering to processing standards, responding to quality issues, partnering with other operational areas to implement performance improvement plans, and ensuring reports are complete and distributed timely. This includes being responsible for providing reports to department leaders on inventory, production, turn-around lag and quality results at an examiner, team, and client level, as required. This individual will be accountable for positively influencing the morale of the department, including setting achievable goals, fostering teamwork by involving team members in the design/implementation of solutions to problems. Responsibilities Include: - Oversight and management of the Claims Quality Assurance Team, including mentoring the team, implementing and coaching through performance improvement plans, and training auditors on job performance expectations. - Reviewing audits of claims, ensuring processing accuracy by verifying all aspects of the audit have been handled correctly and according to both standard processes and the Client’s summary plan description. - Managing the inventory of audits against standard service level agreements (SLA’s) and reporting requirements. - Compiling reporting of audits completed, with decision methodology for procedural and monetary errors which are used for quality reporting and trending analysis utilizing quality tools. - Identifying trends based on the quality reviews, identifies quality improvement opportunities and partners with training team to develop programs. - Partnering with Claims Department Leadership and Training Lead on any problematic issues warranting immediate corrective action. Qualifications: Required Skills and Abilities: - Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others. - Must possess proven organizational, rational reasoning, ability to examine information, and problem-solving skills, with attention to detail necessary to act within complex environment. - Ability to comprehend and produce grammatically accurate, error-free business correspondence required. - Ability to appropriately identify urgent situations and follow the appropriate protocol. - Requires the ability to plan, manage multiple priorities, and deliver complete, accurate, and timely results in a fast-paced office environment. - Ability to work under limited supervision and provide guidance and coaching to others. - Excellent coaching skills and ability to mentor others towards quality improvement - Proficiency in MS Office applications required. Education and Experience: - High School diploma or GED required, Associate or Bachelor’s degree preferred. - Minimum of three (3) years of experience in a claim examiner or quality assurance role with a health care company, meeting production and quality goals/ standards. - Detailed knowledge of relevant systems and proven understanding of processing principles, techniques, and guidelines. - Ability to acquire and perform progressively more complex skills and tasks in a production environment. - Proficient experience in MS Word, Excel, Outlook, and PowerPoint. - Experience with a highly automated and integrated claim adjudication system. Work Location: Candidates located within commuting distance of our Buffalo office will be considered for both in-person and hybrid roles. A ... (truncated, view full listing at source)