Claims Adjustor

About the Company

Centivo is an innovative health plan for self-funded employers on a mission to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills. Anchored around a primary care based ACO model, Centivo saves employers 15 to 30 percent compared to traditional insurance carriers.

Responsibilities

• Adjudicate claims in assigned work queues based on written Policies and Procedures and Summary Plan Documents (SPD).
• Review system-generated edits to ensure benefits are applied correctly per client funds.
• Route claims to Plan Build or Provider Maintenance teams when inconsistencies or pricing discrepancies arise.
• Deny claims for additional information when necessary and generate concise correspondence to participants or providers.
• Maintain daily, weekly, and monthly required production levels.
• Participate in departmental quality improvement and process improvement efforts.
• Process claims under moderate supervision while meeting production and quality goals.

Requirements

• Prior experience with a highly automated and integrated claims processing system.
• Knowledge of healthcare claims, medical coding, and Benefit Plan rules.
• Strong critical thinking and independent decision-making skills.
• Excellent oral and written communication skills.
• Ability to work in a fast-paced environment with production deadlines.
• Proficiency in Microsoft Office and web-based software.
• High School diploma or GED required.

Preferred Qualifications

• Experience working with HealthRules Payer.