Independently performs end to end audits of Operational area to ensure accuracy of departmental processes as they trace back to source and identify (if necessary) process improvement opportunities.
Reports to: Supv. Claims Audit
Location: W Idlewild Ave Tampa, FL
Conducts daily quality reviews of operations department processes (i.e. eligibility, enrollment, claims processing and pricing, configuration contract loads, etc).
Analyze errors and perform root cause analysis in order to determine appropriate classification.
Acts as a Subject Matter Expert for all audit questions and issues.
Assists in monitoring, tracking, and giving direction/feedback to all team members with regards to completion and performance of their daily tasks and responsibilities.
Builds and maintains positive business relationships with business partners.
Participates on conference calls with supervisors/managers to provide audit findings and/or mediate issues with other areas.
Tracks and maintains quality results for appropriate distribution.
Communicates audit results in a structured report format.
Identifies and quantifies issues and recommends audit criteria to validate financial impact.
Navigates audit tools and prepares ad hoc reports using Microsoft Excel or Access to summarize audit findings.
Assists with identification and communication of process improvement opportunities across operation area's based on quality audit reviews.
Maintains productivity expectations.
Conducts new hire training following all policies/procedures and workflow processes.
Assists with special projects and other duties as assigned.
Required A High School or GED
Preferred An Associate's Degree in a related field
Preferred 5 years of experience in practical work within a healthcare organization
Required 3 years of experience in claims processing or provider configuration
Required 1 year of experience in understanding and interpreting contracts as related to claims processing and system configuration
Advanced Knowledge of healthcare delivery Strong functional knowledge and broad multifunctional knowledge of healthcare delivery
Intermediate Demonstrated organizational skills Demonstrated organizational skills with the ability to prioritize, coordinate multiple tasks, and work independently
Advanced Demonstrated time management and priority setting skills
Intermediate Ability to multi-task
Intermediate Ability to work in a fast paced environment with changing priorities
Intermediate Ability to drive multiple projects
Advanced Demonstrated analytical skills
Advanced Demonstrated problem solving skills
Advanced Demonstrated interpersonal/verbal communication skills
Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
Intermediate Ability to work as part of a team
Advanced Ability to work independently
Intermediate Demonstrated organizational skills
Intermediate Other Decision making ability that requires the use of considerable judgment in the analysis of processes and problems/errors resulting from those processes
Intermediate Other Knowledge of HCPCS Coding
Intermediate Other Ability to remain calm under pressure
Intermediate Other Ability to concentrate for extended periods on specific tasks
Licenses and Certifications: A license in one of the following is required: Technical Skills:
Required Intermediate Microsoft Excel Intermediate to advanced knowledge of Microsoft Office
Required Intermediate Microsoft Word
Required Intermediate Microsoft Outlook 1-2 years experience understanding and interpreting contracts as related to claims processing and system configuration
Required Intermediate Microsoft PowerPoint
Preferred Intermediate Other Knowledge of Perot / Peradigm system
Required Intermediate Other Demonstrated technical expertise in performing quality reviews along with analysis of results
About us Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.