We exist for American 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 of Americans who struggle to pay their healthcare bills.
Centivo is looking for a Claims Examiner to join our team!
As a Claims Examiners you will manage and processes health claims for our self-funded employer groups. Healthcare providers treat patients, then file medical claim to receive payment from the patient's Benefit Plan. You will review and assess the claims, ultimately remitting payment to the doctor on behalf of the Plan if a claim is covered by the patient's Benefit Plan.
The Claims Examiner will be responsible for working closely with the Claims Supervisor, Account Managers, System Configuration and Quality Assurance Team in ensuring that claims received by Centivo are adjudicated in a timely manner and accurately.
What you'll do:
- Responsible for adjudicating claims in assigned work queues based on Centivo's written Policies and Procedures and the terms of the Summary Plan Documents (SPD's) 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 to ensure benefits are being applied per the clients SPD and client funds are being appropriately managed.
- 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 Plan Build/System Configuration Team for resolution.
- In situations where the Claims Examiner is unable to resolve an edit based on the provider selection, the pricing and/or usual and customary discrepancies, immediately routing the claim the Provider Maintenance and/or Pricing teams 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.
- Claim Examiners are required to maintain daily, weekly, and monthly required production levels documented in Claims Department Policies and Procedures.
- Participation in Departmental quality improvement efforts, and expected to bring forward process improvement suggestions that will improve efficiencies; questioning a process or policy that creates additional steps or work on the Examiner and suggesting an alternative solution
You should have:
- knowledge about health care claims, medical coding, and rules applicable to Benefit Plans.
- Must have prior experience with the Javelina system or another highly automated and integrated system like Javelina.
- Problem solving skills are essential and willingness to make independent decisions with little supervision
- Must be available during standard working hours and willing to work over-time as business need requires.
Flexible shifts, work from home and remote locations are available if quality and production goals are consistently met.
Education and years of experience will determine what level you are considered for.
This role is primarily located in our Buffalo, NY and can be remote based on experience
Who we are:
Centivo is a new type of health plan for self-funded employers that is built to save 15 percent or more compared to traditional insurance carriers and is easy to use for employers and employees.
Centivo's mission is to bring lower cost, higher quality healthcare to the millions of working Americans who struggle to pay their healthcare bills. With Centivo, employers can offer their employees affordable and predictable costs, a high-tech member experience, exceptional service, and a range of benefit options including both traditional and proprietary networks. Centivo develops high-value networks in partnership with leading local healthcare providers and uses data analytics to refine the network and navigate members to the right providers. Members get a partner for all their healthcare needs through a primary care-centered model, as well as expanded access and fully integrated virtual care.
With offices in New York City, Buffalo, NY and Denver, CO, Centivo is backed by leading investors including Bain Capital Ventures, Maverick Ventures, Bessemer Venture Partners, Ingleside Investors, Rand Capital, Company Ventures, and Oxeon Investments. Learn more at Centivo.com.