Pharmacy Claims Auditor

Position Purpose: Claims Auditor is responsible for the quality audit of a variety of specific processes within the operations services for Claims to ensure quality service goals and standards are met and/or identify areas where improvement can be achieved. Provides audit feedback regarding the exceptions, patterns and trends to management.

Key Details: Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.

• Performs routine and moderately complex audits to identify trends, issues, and exceptions to the established claims adjudication requirements. Reports to management when quality standards impact the business unit, company, affiliates and/or clients and customers.
• Proactively identifies performance trends/patterns of audits to management, and makes recommendations to improve quality, workflow processes, policies and procedures.
• Provides timely review and completion on all contested claims.
• Researches claim processing problems and errors to determine their origin and provides appropriate feedback to examiners, trainers and management.
• Manually enters audit data into the database to develop reports based on the audit findings.
• Provides coaching and feedback to examiners and management on prepayment and post payment findings and trends.
• Provides recommendations for additional training or updates that will help prevent further errors to enhance service and productivity within Health Net.
• Maintains a comprehensive working knowledge of Policies, Procedures, Compliance Regulations, Schedule of Benefits and turn around times across all product lines.
• Participates in specialized training within departments.
• Monitors daily assignments and prioritizes aged audits to ensure all audits are completed timely per regulatory and department guidelines.
• Performs other related duties as assigned.

Education/Experience: High School Diploma required. Minimum one year relevant experience . In-depth experience in Health Care Claims, Contracts, Benefit Application, Coordination of Benefits.

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
 

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.  Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status.  Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act