Supv, Claims Audit

Location: Idlewild Ave, Tampa, FL

Reporting to: Dir, Claims Audit

Department: Ops-Provider Operations

Position is responsible for overseeing, giving direction/feedback to their Audit team members with regard to completion and performance of their daily tasks and responsibilities. Acts as a subject matter expert for all audit questions/issues.

Essential Functions:

  • Acts as a Subject Matter Expert (SME).
  • Reviews all second level rebuttals.
  • Reviews Peer Review scores with Auditors and recommends process improvement.
  • Works with Manager to maintain appropriate work balance in the department in order to maximize productivity.
  • Assists in developing of long-range goals for claims audit specialist and Sr. claims audit specialists.
  • Accept the responsibilities of the manager of Claims Audit in his/her absence and ensure that the department runs smoothly & without disruption to the daily routine.
  • Researches and recommends solutions for escalated issues. Presents proposed solutions in a clear and concise manner.
  • Responsible for performance management responsibilities for direct reports.
  • Assists with developing and maintaining departmental policies and procedures including desk top procedures.
  • Assists with developing training materials for the department and facilitate training as needed.
  • Analyzes errors and performs root cause analysis in order to determine appropriate classification.
  • Presnts audit findings and / or mediates issues external to the department.
  • Assists with identification and communication of process improvement opportunities across operation areas based on quality reviews.
  • 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 a healthcare organization
    • Required 5 years of experience in understanding and interpreting contracts as related to claims processing and system configuration

    Candidate Skills:

    • Advanced Knowledge of healthcare delivery
    • Intermediate Demonstrated organizational skills
    • Intermediate Demonstrated time management and priority setting skills
    • Intermediate Ability to drive multiple projects
    • Intermediate Ability to work independently
    • Advanced Demonstrated analytical skills
    • Advanced Demonstrated problem solving skills
    • Advanced Demonstrated interpersonal/verbal communication skills
    • Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
    • Intermediate Ability to work as part of a team
    • Intermediate Ability to work in a fast paced environment with changing priorities
    • Intermediate Ability to multi-task
    • 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
    • Advanced Other Ability to facilitate small group meetings
    • Advanced 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:

    • Preferred Other Certified Medical Coder

    Technical Skills:

    • Required Intermediate Microsoft Excel
    • Required Intermediate Microsoft Outlook
    • Required Intermediate Microsoft Word
    • Required Intermediate Microsoft PowerPoint
    • Required Intermediate Other Demonstrated technical expertise in performing quality reviews along with analysis of results
    • Preferred Intermediate Other Knowledge of Perot / Peradigm system


      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.