Claims FWA & Reporting Analyst - C1

Reviews daily, weekly, and monthly reports to ensure accurate claims processing prior to adjudication. Performs data analysis and review and approval of FW&A recommendations prior to adjudication. Serves as a subject matter expert on claims adjudication for the Medicaid and Medicare lines of business within the health plan.

Department: Ops, Claims

Report To: Mgr, Strategic Operations

Location: Phoenix, AZ 85016



Essential Functions:

  • Handles all claims reports, encounter reversals and E-Status claims review within designated timeframes.
  • Reviews, analyzes and makes final acceptance of FW&A recommendations within 24-business hours of response file from FW&A vendor.
  • Reviews monthly reports for identification of system enhancements and process changes to ensure accurate adjudication on a go-forward basis.
  • Completes daily reports promptly and efficiently, identifying training opportunities, documentation needs, and system updates to minimize future instances.
  • Proactively identifies adjustment sources in order to minimize the volume of claims that require secondary handling, generating ideas and creating solutions to improve or simplify procedures, techniques, and processes.
  • Researches, reviews and accurately adjudicates CMS-1500 and UB claims of all levels of complexity, correcting claims prior to adjudication.
  • Tracks and trends claims processing issues related to auto-adjudication and employee handling of claims, and assists Claims Department in identifying and quantifying issues along with reviewing Claims Department work processes as requested.
  • Identifies and assists in conducting additional claims training needed for internal staff as needed.
  • Perform 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 3 years of experience in claims processing including COB/TPL and claim reversals and adjustments.
    • Required 1 year of experience in MHC claims processing
    Candidate Skills:
    • Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
    • Intermediate Demonstrated analytical skills
    • Intermediate Demonstrated problem solving skills
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Intermediate Ability to multi-task
    • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
    • Intermediate Ability to work in a fast paced environment with changing priorities
    • Intermediate Demonstrated organizational skills
    • Intermediate Ability to work independently
    • Intermediate Demonstrated written communication skills
    • Intermediate Ability to effectively present information and respond to questions from peers and management
    • Intermediate Other Attention to detail with high level of accuracy
    • Beginner Other Basic knowledge of procedures used in fraud, abuse and waste detection and investigation
    • Intermediate Other Knowledgeable in AHCCCS and CMS rules/regulations/reference tools/policy manuals, etc.
    • Intermediate Other Detailed understanding of claims processing of institutional and/or professional claims
    Licenses and Certifications:
    A license in one of the following is required:
      Technical Skills:
      • Required Intermediate Microsoft Excel
      • Required Beginner Microsoft Word
      • Required Beginner Microsoft Outlook
      Languages:
      • Preferred English

      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 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.