Oct 19, 2019

Claims Audit Specialist, Sr

  • Professional Diversity Network
  • Tampa, FL, USA
Full-Time Facilities

Job Description

WellCare Health Plans

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.

Department: Ops-Quality

Reports to: Supv. Claims Audit

Location: W Idlewild Ave Tampa, FL

Essential Functions:

  • 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.
Additional Responsibilities:

Candidate Education:

  • Required A High School or GED
  • Preferred An Associate's Degree in a related field
Candidate Experience:
  • 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
Candidate Skills:
  • 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.



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