Director, Coding Integrity (Remote Opportunity)

Department - Operations - Payment Integrity

Reports to: Sr. Director Strategic Initiatives

Location: 5520 Idlewild Ave Tampa FL 33634

Manages a team of associates and vendors who are responsible for corporate claims coding and payment rules functions to ensure compliance with Federal, State and contractual requirements. Oversees programs related to CMS, State Medicaid, and industry coding guidelines that provide claims expense savings through proper upfront claims coding adjudication.

Essential Functions:

  • Directs and oversees claims pre-payment adjudication activities with the objective of meeting production, timeliness and quality standards.
  • Implements initiatives by managing an action plan, coordinating action steps with business partners, driving resolution of implementation related issues and education of business partners.
  • Responsible for the performance management processes for direct reports including coaching, counseling, providing feedback, career planning, goal setting, and performance assessment.
  • Manages process improvement initiatives, seeking root cause and developing appropriate corrective action.
  • Establishes objectives, goals and performance measures for the function being managed.
  • Coordinates activities to ensure key deliverables are met and resolves conflicting demands.
  • Oversees and directs all vendor relationships specific to claims coding edits.
  • Projects and reports cost savings through identification of coding guidelines and upfront claim coding edits.
  • Assists in developing both short and long range plans for overall departmental activities.
  • Oversee the implementation of programs and strategies.
  • Performs other duties as assigned.
Additional Responsibilities:
    Candidate Education:
    • Preferred A Bachelor's Degree in a related field
    Candidate Experience:
    • Required 5 years of experience in a health care payer/provider (hospital, multi-specialty physician) organization - with a Bachelor's degree
    • Required 7 years of experience in a health care payer/provider (hospital, multi-specialty physician) organization - without a Bachelor's degree
    • Required Other Strong analytics in claims processing/coding and/or testing, preferably in healthcare
    • Required 3 years of management experience
    • Preferred Other Project Life-cycle experience
    • Required Other Experience working with health insurance claims payment systems and government payment systems
    Candidate Skills:
    • Advanced Other Professional knowledge of medical terminology and abbreviations
    • Advanced Other Knowledge of Medicaid payment systems, including ability to quickly research and absorb new payment systems
    • Advanced Demonstrated project management skills
    • Advanced Demonstrated organizational skills
    • Intermediate Ability to analyze and interpret financial data in order to coordinate the preparation of financial records
    • Intermediate Demonstrated leadership skills
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Intermediate Demonstrated written communication skills
    • Intermediate Ability to analyze and interpret financial data in order to coordinate the preparation of financial records
    • Intermediate Ability to drive multiple projects
    • Intermediate Ability to work in a fast paced environment with changing priorities
    Licenses and Certifications:
    A license in one of the following is required:
      Technical Skills:
      • Required Intermediate Other Proficiency in Microsoft Office software applications, data cubes and databases
      • Required Intermediate Other Knowledge of one or more of the following: SQL, Xcelys, CES, iHT
      • Required Intermediate Other Medical Billing and Coding
      • Required Intermediate Other Claim reimbursement methodologies

        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.