Claims Audit Specialist, Lead','1800763','!*!About WellCare: WellCare Health Plans, Inc. is a Fortune 500 company traded on the New York Stock Exchange (symbol: WCG). It provides managed care services targeted to government-sponsored health care programs, including Medicaid, Medicare, Prescription Drug Plans and the Health Insurance Marketplace. Headquartered in Tampa, Fla., WellCare offers a variety of health plans for families, children, and the aged, blind and disabled. The company serves approximately 4 million members and employs approximately 6,500 people nationwide as of Sept. 30, 2014. For more information about WellCare, please visit our website at www.wellcare.com or view our videos at https://www.youtube.com/user/WellCareHealthPlan.EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, sex, age forty (40) and over, disability, veteran status, or national origin.','!*!
LOCATION: Woodland Corporate Blvd, Tampa, FL 33607
DEPARTMENT: FL - Operations
REPORTING TO: Supervisor, Claims Audit
Independently performs peer reviews of Claims Audit staff and conducts department training. Monitors, tracks, and gives direction/feedback to Claims Audit Specialists with regard to completion and performance of their audit tasks and responsibilities. Controls and maintains training materials and policies and procedure. Acts as an Audit Subject Matter Expert (SME) for all audit questions/issues. Essential Functions:
Serves as a mentor for all Claims Audit Specialists and provides real-time feedback for the job function.
Serves as a SME and Lead Auditor.
Performs peer reviews of audit staff and reviews scores with supervisor/manager and recommends process improvement as needed.
Works with management to maintain a well trained work force in the department in order to ensure a high quality control program.
Assists in developing goals for auditors.
Works with supervisor to manage the Individual Training Plans for each auditor.
Researches and proposes solutions for escalated issues in a clear and concise manner.
Assists with developing and maintaining departmental policies and procedures including desk top procedures.
Leads in developing training materials for the department and faciliates training as needed.
Analyzes errors and performs root cause analysis in order to determine appropriate classification.
Builds and maintains positive business relationships with business partners.
Conducts claim audits in a lead role for internal and external entities.
Participates on conference calls with supervisors/managers to provide audit findings and/or mediate issues.
Communicates audit results in a structured format.
Assists with identification and communication of process improvement opportunities across operation area's based on quality reviews.
Performs additional duties as assigned. i.e. Release high dollar claim audits & distribute workload. Additional Responsibilities: ','!*!Candidate Education:
Preferred A Bachelor's Degree in a related field Candidate Experience:
Required 5 years of experience in a healthcare organization
Required 3 years of experience in understanding and interpreting contracts as related to claims processing and system configuration
Preferred 2 years of experience in a Sr. Claims Auditor role in a healthcare organization 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
Intermediate Demonstrated time management and priority setting skills
Intermediate Ability to drive multiple projects
Advanced Ability to work independently
Advanced Demonstrated analytical skills
Advanced Demonstrated problem solving skills
Intermediate 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
Intermediate Ability to work in a fast paced environment with changing priorities
Intermediate Ability to multi-task
Intermediate Other Decision making ability that requires the use of considerable judgement in the analysis of processes and problems/errors resulting from those processes
Intermediate Other Knowledge of HCPCS Coding
Intermediate Other Ability to facilitate small group meetings
Intermediate Other Ability to remain calm under pressure
Intermediate Other Ability to concentrate for extended periods on specfic tasks Licenses and Certifications:A license in one of the following is required:
Preferred Other Certified Medical Coder Technical Skills:
Required Intermediate Microsoft Excel
Required Intermediate Microsoft Outlook
Required Intermediate Microsoft Word
Required Intermediate Microsoft PowerPoint
Required Intermediate Other Demonstrated technical expertise in performing quality reviews along with analysis of results
Preferred Intermediate Other Knowledge of Perot / Peradigm system Languages:
','US-FL-Tampa','7840 Woodland Corporate Blvd','','Tampa','33614','','','No','No','Claims Audit Specialist, Lead
Website : http://www.wellcare.com
WellCare Health Plans, Inc. focuses exclusively on providing government-sponsored managed care services, primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, to families, children, seniors and individuals with complex medical needs. The company served approximately 3.8 million members nationwide as of Sept. 30, 2015. For more information about WellCare, please review our website and view the company’s videos. WellCare has developed a full complement of expertise in three major areas of government-sponsored health care…. Medicaid, Medicare Advantage and Medicare Prescription Drug Plans. Leveraging our expertise for our members' benefit is a key part of the value we bring to our members. WellCare focuses on those members who are dually eligible for both Medicaid and Medicare. This is an area of specialization that many other health plans simply do not have. We are committed to continually improving the quality of care and service that we provide to our members. We help our members access the right care at the right time in the appropriate setting. For some members, this includes the use of coordinated care teams and community partnerships. And we’re focused on government customers and use a disciplined approach to ensure a competitive cost structure.