Provider Operations Auditor

Participates in market operational audits, and coordinates all operational audit related activities across various functional areas in support of operational goals. Provides ongoing coordination, analysis, and communication of operational compliance to all of the market operations. Supports the process to maintain the integrity of provider network data by reconciling discrepancies within existing data and presented in provider network reports sent to the state agency. Completes online research and/or conducts phone, email, or fax validations to coordinate the updating of source systems with accurate information.

Reports To: Supervisor, Provider Operations

Department: Provider Relations

Position Location: Telecommute

Essential Functions:

  • Researches, understands, problem solves and reports root cause of metric variances, and proposes possible business solutions in reports submitted regularly to the state/regional agency.
  • Serves as a subject matter expert regarding all process flows including understanding systems used and functions performed within each work type, dependencies/interactions and identification of potential impact resulting from changes.
  • Develops and maintains interdepartmental relationships to ensure proper involvement, cooperation and communication of changes are executed appropriately.
  • Assists with audit reviews of reports submitted to the state/regional agency for accuracy, and provides timely feedback on findings. Type of audits include PCP load demographics, all newly added/updated provider loads, hospital and facility state-wide rates, regulatory research to ensure payment rule compliance and validation on all market specifics or CMS rate update fee schedules.
  • Communicates clearly, both written and verbal, and follows up with various areas to ensure tasks are completed or issues are escalated appropriately.
  • Performs quality checks throughout the directory process to ensure accuracy in the data and reporting.
  • Assists in the development and maintenance of various policies and procedures affecting the operations of the department.
  • Provides ongoing operational analysis of process components, while identifying and implementing changes as necessary to improve the level of quality and efficiency as measured by key performance indicators.
  • Performs special projects as assigned.
Additional Responsibilities:
  • Acts as a mentor to associates. Provides real-time feedback as appropriate for the job function.
  • Acts as a liaison between internal departments on data gathering and problem solving.
  • Provides training to new and current members of the staff.
Candidate Education:
  • Required A High School or GED
  • Preferred A Bachelor's Degree in a related field
Candidate Experience:
  • Required 4 years of experience in operational support, operational auditing or provider/network development administration support
  • Required 2 years of experience in managed care
Candidate Skills:
  • Intermediate Ability to multi-task
  • Beginner Demonstrated analytical skills
  • Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
  • Intermediate Ability to analyze information and covert related activities into a comprehensive work plan
  • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
  • Intermediate Ability to proof large bodies of materials
  • Intermediate Ability to work independently
  • Intermediate Ability to work in a matrixed environment
  • Intermediate Demonstrated interpersonal/verbal communication skills
  • Intermediate Demonstrated organizational skills
Licenses and Certifications:
A license in one of the following is required:
    Technical Skills:
    • Required Intermediate Microsoft Excel
    • Required Intermediate Microsoft Outlook
    • Required Intermediate Microsoft Word

      About us
      Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. 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.