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Claims Examiner

 

Centivo is a new type of health plan administrator that allows self-funded employers and clinicians to join forces and deliver high quality, affordable healthcare to their employees. An alternative to traditional insurance carriers or third-party administrators, Centivo offers the technology, network, claims processing, customer support, and population health management to fully administer health benefits for all or a portion of an employee population.

 

At Centivo, we never lose sight of the fact that we are dealing with healthcare, with emotions, with anxiety, with fear, and with lives. We treat your employees and their families with the same level of care that we would use to treat our own families.

Summary of this role:

Claims Examiners manage and processes health claims for our self-funded employer groups.  Claim Examiners review and assess the claims, ultimately remitting payment to the provider on behalf of the Plan if a claim is covered by the patient’s Benefit Plan. It is vital that the processor be knowledgeable about health care claims, medical coding and rules applicable to Benefit Plans.  Problem solving skills are essential.

 

The Claims Examiner will be responsible for working closely with the Claims SME, Director of Claims,and Vice President of Operations in ensuring that claims received by Centivo are adjudicated in a timely manner and accurately. This role will be located in our Buffalo, NY office or work from home.

In this position you will have the following responsibilities:

Responsibility for adjudicating claims in assigned work queues based on Centivo’s written Policies and Procedures and the terms of Plan Documents for Centivo’s clients;

  • Diligently reviewing all system-generated edits which have been applied to claims in the Examiner’s assigned queues prior to releasing the claims;
  • In situations where the Examiner believes there may be an issue or inconsistency in the interpretation of a Plan as the system is applying benefits, immediately routing the claim to the Claims SME or Plan Builder for resolution;
  • In situations where the Claims Examiner is unable to resolve an edit based on the information included with or attached to a claim, appropriately denying the claim for additional information and generating correspondence to the participant or provider concisely explaining data needs. When such additional data is received, reopening the denied claim and re-adjudicating based on the information;
  • Maintaining daily, weekly and monthly required production levels documented in Claims Department Policies and Procedures;
  • Maintaining minimum quality levels, measured by Financial Accuracy, Payment Accuracy, Procedural Accuracy and Adjustments Caused by Examiner Error which are documented in Claims Department Policies and Procedures;
  • Participation in Departmental quality improvement efforts; and
  • Attendance which meets Centivo standards.

Qualifications:

Candidates must have at least 3 years of experience with TPA claims processing.  Ideally, candidate would have prior experience with the Javelina system or another highly-automated and integrated system similar to Javelina.  There will be a Knowledge Assessment administered during the interview process and candidate must successfully pass that Assessment to be considered.

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