Claims Audit Specialist

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.

Essential Functions:
  • Conducts daily quality reviews of operations department processes (i.e. eligibility, enrollment, claims processing and pricing, configuration contract loads, etc).
  • Responds to first and second level rebuttals in a timely manner.
  • Tracks and maintains quality results for appropriate distribution.
  • Communicates audit results in a structured report format.
  • Identifies and quantifies issues and recommend 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.
  • 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:
    • Required 2 years of experience in direct claims processing or provider configuration
    Candidate Skills:
    • Advanced Knowledge of healthcare delivery Strrong functional knowledge of healthcare delivery
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Intermediate Ability to work independently
    • Intermediate Ability to work as part of a team
    • Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
    • Intermediate Ability to work in a fast paced environment with changing priorities
    • Intermediate Demonstrated time management and priority setting skills
    • Intermediate Demonstrated organizational skills
    • Intermediate Ability to multi-task
    • Intermediate Other Understanding of managed care and the health care industry in general
    • Intermediate Other Ability to understand and interpret contracts as related to claims processing or configuration
    • 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 Demonstrated technical expertise in performing quality reviews along with analysis of results
      • Required Intermediate Microsoft Outlook Knowledge of CPT/HCPCS Coding
      • Required Intermediate Microsoft Word Intermediate to Advanced knowledge of Microsoft office
      • Required Intermediate Microsoft PowerPoint
      • 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 exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. For more information about WellCare, please visit the company's website at 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.