Job Title: Quality Assurance Claims Auditor
Location: Remote
Experience Required: 2 3 Years
Position Overview
The Claims QA Associate is responsible for validating members' Out-of-Pocket Maximum (OOPM) cost shares based on audit years listed in the Accumulator Overages Report. This role requires careful review of member responsibilities aligned with plan benefits, ensuring OOPM limits and any overages are accurately identified according to Centene's predefined audit criteria. When a member exceeds their OOPM limit, the associate ensures appropriate reimbursement through medical claims and pharmacy adjustments.
Key Responsibilities
Conduct accurate validation of OOPM cost shares based on audit data.
Review and analyze plan benefits to ensure correct application of member responsibilities.
Identify and validate any OOPM overages and ensure correct reimbursement processes are triggered.
Perform adjudication and adjustment of claims with zero errors.
Complete assigned claims queues within the specified timeframes.
Maintain quality standards and comply with all audit guidelines.
Required Skills & Qualifications
1 3 years of hands-on experience in claims processing or claims auditing.
Strong logical reasoning and analytical thinking skills.
Working knowledge of the US Healthcare industry, insurance terminology, and claims workflows.
Proficiency in MS Office applications (Excel, Word, Outlook).
Excellent attention to detail, accuracy, and time management.
Education & Experience
Minimum 3 years of relevant experience preferred.
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