At WellCare, we are a passionate team with a strong mission and a focused purpose: to serve our members and communities in which they live while helping them live better, healthier lives. Our culture is one of empowerment, teamwork and commitment as we all work together to deliver cost-effective solutions that create positive outcomes for our members. Join us a career that inspires passion and purpose across all levels and disciplines within our award-winning organization.
Location: 5301 W Idlewild
Reporting to: Mgr,
Collects and analyzes data to evaluate operational obstacles which include revenue and compliance issues, and makes recommendations to resolve issues in a timely matter. Uses the medical classification system to design the benefit packages with proper ICD-9, CPT-4, HCPCS for configuration into the Peradigm, Tableau or other related system. Disseminates benefit determinations to key stakeholders administering benefits (health services, configurations, etc.) throughout the organization. Serves as an integral role in the testing, analysis and benefit configuration of new and existing plans.
Reviews, analyzes and translates diagnostic procedural phrases into coded form.
Updates and maintains adjudication system with defined code sets in logical order.
Coordinates with internal operations departments to ensure data accuracy.
Produces reports from the Peradigm System to analyze necessary modifications to codes sets, BRULES and MEDEFs.
Creates testing scripts for new and existing plans.
Assists in the on-going evaluation of the benefit configurations within the Peradigm System for new and existing benefit plans.
Documents the configuration of new plans as well as changes in existing plans.
Provides feedback to stakeholders regarding feasibility and requirements for enhancements to benefit configuration.
Provides research assistance for the resolutions of benefit issues.
Serves as a liaison of benefit configuration to external departments.
Collects and analyzes data to evaluate operational difficulties and makes recommendations to solve problems.
Performs special projects as needed.
Required An Associate's Degree in CIS, BIS, Coding or related field
Required Other or equivalent of 1 year work experience in lieu of degree
Required 2 years of experience in medical coding, configuration or claims
Intermediate Other Applies coding knowledge to ascertain codes sets for each service
Intermediate Other Ability to break procedures down at a granular level and organize data in a logical manner
Intermediate Other Ability to conduct Internet research to update code sets
Licenses and Certifications:
A license in one of the following is required:
Required Intermediate Other Peradigm (Diamond), Tableau or other related system
Preferred Intermediate Microsoft Access
Preferred Intermediate SQL Server System
Required Intermediate Microsoft Word
Required Intermediate Microsoft Outlook
Preferred Intermediate Other Knowledge of organization of data within medical adjudication systems
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.