Senior Quality Auditor

🔥 2 hours ago

🏰 Missouri – Remote

🏰 Missouri – Remote

💵 $23 - $39 / hour

⏰ Full Time

🟠 Senior

🔎 Auditor

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

📋 Description

• Develop and implement effective business solutions through research, audit, and data and/or business-process analysis • Audit and validate routine pre- and post-payment claims for correct adjudication and compliance • Audit provider data loaded into claims processing systems • Document and report audit results • Research claims and enrollment discrepancies related to provider data • Manage provider-data-management-related projects requiring advanced knowledge of provider files and their relationship to claims processing systems • Review and support the claims process for medical review and cost-saving initiatives • Maintain department statistics for quality improvement indicators, regulatory agencies and certification bodies • Perform routine and moderately complex audits on medical review claims to identify exceptions • Research reviewed-claim issues to determine origins and appropriate resolutions • Summarize findings and recommendations in reports and distribute them to management • Communicate audit and review results to the claims department to improve claims processing and resolutions • Provide qualified data for training programs, policies and procedures • Maintain current working knowledge of Health Net products, policies, procedures, coding, and applicable industry standards

🎯 Requirements

• Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future • High School Diploma or equivalent • Four years general data management experience in an automated claims processing, claims research, or provider maintenance environment • Some college coursework preferred • Working knowledge of Health Net products, policies and procedures • Knowledge of contract and benefit plan coding • Knowledge of health insurance industry, regulation and certification standards • Ability to audit and validate claims • Ability to research claims and enrollment discrepancies related to provider data • Ability to document and report audit results • Ability to work remotely within the continental United States • Preferred schedule based on Central Standard Time or Eastern Standard Time

🏖️ Benefits

• Competitive pay • Health insurance • 401K • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Additional forms of incentives may be included in total compensation, subject to eligibility