Claims Auditor

About the role

Centivo is hiring a Claims Auditor to oversee the accuracy and integrity of our claims processing operations. You will manage pre-payment and post-payment audits to ensure our healthcare plans meet strict quality standards and financial requirements.

Key facts

What you'll do

• Audit internal and external claims to verify financial and processing accuracy against client summary plan descriptions.
• Document audit results and identify procedural or monetary errors using quality assurance tools.
• Coordinate with Claims Adjustors to correct high-dollar claims and verify that adjustments are accurate.
• Track quality trends and escalate issues to leadership when necessary.
• Collaborate with supervisors and managers to refine processing guidelines and support performance improvement initiatives.
• Mentor Claims Adjustors and assist with training or policy development as needed.

Requirements

• High School diploma or GED.
• Minimum of 3 years of experience as a claims auditor or adjustor within a TPA environment focused on self-funded health plans.
• Proficiency in MS Word, Excel, Outlook, and PowerPoint.
• Demonstrated ability to meet production and quality benchmarks.
• Strong organizational, analytical, and interpersonal communication skills.

Nice to have

• Associate or bachelor's degree.
• Experience with automated claims systems, specifically El Dorado-Javelina or Health Rules Payer (HRP).
• Experience providing coaching and mentorship to team members.
• Ability to manage complex tasks with minimal supervision.

Skills & tools

• Claims auditing
• TPA processing principles
• Quality assurance reporting
• MS Office Suite
• El Dorado-Javelina (preferred)
• Health Rules Payer (preferred)

Practical notes

Candidates living near the Buffalo office may work in-person or in a hybrid capacity. All other candidates will be considered for remote work.