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Senior Claims Examiner

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  • Company: Centivo
  • Posted: 06/08/2022
  • Location: Buffalo, NY
  • Category: Customer Support
  • Job Type: Direct Placement
  • Experience Level:

Description


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 Senior Claims Examiner to join our team!

As a Sr. Claims Examiner you will process claims in accordance with established policies and procedures, contact providers as needed, complete tasks independently.  Support all Centivo products and claims of higher complexity.  Document processes, perform advanced tasks, and provide the highest level of support to team members.  Will work on various claim and/or client projects as needed, respond to appeals, support high dollar reviews, overpayment/refunds, and subrogation process.  Maintain production goals determined by the supervisor and quality standards of 98-99% accuracy.

What you’ll do:

  • Responsibility 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:

  • Minimum experience level is 5-8 years
  • Perform as a back up to the Subject Matter Expert (SME) or supervisory role as needed
  • Ideally, candidate must have prior experience with the Javelina system or another highly automated and integrated system like Javelina.

There will be a Knowledge Assessment administered during the interview process and candidate must successfully pass that Assessment to be considered.

Location:

This position located in the Buffalo, NY office with some flexibility to work from home occasionally.

Salary range:

Our range for this role is $50,000 – $60,500.  To determine our range, we consider as many of the following data points as are available to us: external market salary survey data, internal data in terms of comparable roles and our budget for the position. Compensation is both an art and a science (as is negotiating a salary for a new job at a new company!), so what we have posted is our good faith estimate of what we expect to pay. We encourage candidates to apply for positions that are of interest and share their desired salary. We consider that as an additional data point, along with candidate skills and qualifications as part of our process.

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.

Headquartered in Buffalo, NY with offices in New York City and Buffalo, Centivo is backed by leading investors including B Capital Group, Bain Capital Ventures, Bessemer Venture Partners, Company Ventures, Define Ventures, F-Prime Capital, HarbourVest Partners, Ingleside Investors, Maverick Ventures, Nassau Street Ventures (an AVG fund), and Oxeon Investments.

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