Mgr, Claims Audit

Oversees all audit types, considers issues and impacts at a departmental level, and has ongoing collaboration with key business partners to identify and root cause process issues. Manages performance of claim audits to determine financial risk and user compliance. Assists in developing policies and procedures to support operational audit process and reporting. Facilitates training and development of audit team members.

Essential Functions:
  • Tracks audit results for distribution and maintenance within Audit DB.
  • Communicates regularly with other areas and facilitates issues related to audit results, rebuttals, and mediations.
  • Identifies special audit opportunities based on trending analysis and claim activity related to payment corrections and financial errors.
  • Manages and develops direct reports who include, supervisory personnel, and/or exempt and non-exempt individual contributors. Directs work assignments, measures results, and initiates personnel actions as required for assigned claims audit units.
  • Recruits, selects, trains and retains highly qualified professionals. Mentors lower level management for succession planning.
  • Ensures all productivity and quality standards are met, and develops course for improving when necessary. Proactively seeks improvements to productivity, quality and timeliness measures and implements solutions at a departmental level.
  • Presents information to all levels of the organization regarding audit results, auditor performance, and recommendations for process improvement.
  • Serves as subject matter expert for audit operations and claim related issues to facilitate final error disposition.
  • Performs additional duties as assigned.
Additional Responsibilities:
    Candidate Education:
    • Required A High School or GED
    • Preferred A Bachelor's Degree in a related field
    Candidate Experience:
    • Required 5 years of experience in directly related area
    • Required 3 years of experience in people leadership and management
    • Required 4 years of experience in interpreting contracts as related to claims processing and system configuration
    • Preferred 4 years of experience in managed care claim payments processes
    Candidate Skills:
    • Intermediate Other Claims Processing/Configuration knowledge, both professional and Institutional
    • Intermediate Ability to lead/manage others
    • Intermediate Ability to influence internal and external constituents
    Licenses and Certifications:
    A license in one of the following is required:
      Technical Skills:
      • Required Intermediate Microsoft Outlook
      • Required Intermediate Microsoft Word
      • Required Intermediate Microsoft Excel
      • Required Advanced Microsoft PowerPoint
      • Required Intermediate Microsoft Project •Knowledge of additional software programs as necessary.
      • Required Intermediate Microsoft Access
      • 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.