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Centivo is growing and looking to hire Claims Examiners II to join our team!

Claims Examiners manages 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. Claim Examiners 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. You 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:

• 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.
• Working cross-functionally:
  • When 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.
  • When 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.
  • When 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.
• Maintain daily, weekly, and monthly required production levels documented in Claims Department Policies and Procedures.
• Participation in Departmental quality improvement efforts, expected to bring forward process improvement suggestions that will improve efficiencies
• Question a process or policy that creates additional steps or work on the Examiner and suggesting an alternative solution
• Responsible for clients in the same or across products
• Meet the production goals determined by the supervisor, and quality standards of 98-99% accuracy

You should have:

• Minimum experience level is 2-3 years or equivalent experience, can assist and mentor less experienced team members
• knowledgeable about health care claims, medical coding, and rules applicable to Benefit Plans
• Problem solving skills are essential and willingness to make independent decisions with little supervision
• Prior experience with Javelina system or another highly automated and integrated system

Location:

This role is primarily located in our Buffalo, NY.

Flexible shifts, work from home and remote locations are available if quality and production goals are consistently met.