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Corporate Functions & Operations WellCare - Claims Careers

Claims Audit Specialist - Lead Job

Full Job Title: Claims Audit Specialist, Lead

Job Number: 1800763

Location: Tampa, FL

Date Posted: 2-14-2018

LOCATION: Woodland Corporate Blvd, Tampa, FL 33607

DEPARTMENT: FL - Operations

REPORTING TO: Supervisor, Claims Audit

Independently performs peer reviews of Claims Audit staff and conducts department training. Monitors, tracks, and gives direction/feedback to Claims Audit Specialists with regard to completion and performance of their audit tasks and responsibilities. Controls and maintains training materials and policies and procedure. Acts as an Audit Subject Matter Expert (SME) for all audit questions/issues.

Essential Functions:

  • Serves as a mentor for all Claims Audit Specialists and provides real-time feedback for the job function.
  • Serves as a SME and Lead Auditor.
  • Performs peer reviews of audit staff and reviews scores with supervisor/manager and recommends process improvement as needed.
  • Works with management to maintain a well trained work force in the department in order to ensure a high quality control program.
  • Assists in developing goals for auditors.
  • Works with supervisor to manage the "Individual Training Plans" for each auditor.
  • Researches and proposes solutions for escalated issues in a clear and concise manner.
  • Assists with developing and maintaining departmental policies and procedures including desk top procedures.
  • Leads in developing training materials for the department and faciliates training as needed.
  • Analyzes errors and performs root cause analysis in order to determine appropriate classification.
  • Builds and maintains positive business relationships with business partners.
  • Conducts claim audits in a lead role for internal and external entities.
  • Participates on conference calls with supervisors/managers to provide audit findings and/or mediate issues.
  • Communicates audit results in a structured format.
  • Assists with identification and communication of process improvement opportunities across operation area's based on quality reviews.
  • Performs additional duties as assigned. i.e. Release high dollar claim audits & distribute workload.
Additional Responsibilities:Candidate Education:
  • Preferred A Bachelor's Degree in a related field
Candidate Experience:
  • Required 5 years of experience in a healthcare organization
  • Required 3 years of experience in understanding and interpreting contracts as related to claims processing and system configuration
  • Preferred 2 years of experience in a Sr. Claims Auditor role in a healthcare organization
Candidate Skills:
  • Advanced Knowledge of healthcare delivery Strong functional knowledge and broad multifunctional knowledge of healthcare delivery
  • Intermediate Demonstrated organizational skills Demonstrated organizational skills with the ability to prioritize, coordinate multiple tasks, and work independently
  • Intermediate Demonstrated time management and priority setting skills
  • Intermediate Ability to drive multiple projects
  • Advanced Ability to work independently
  • Advanced Demonstrated analytical skills
  • Advanced Demonstrated problem solving skills
  • Intermediate 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 judgement in the analysis of processes and problems/errors resulting from those processes
  • Intermediate Other Knowledge of HCPCS Coding
  • Intermediate Other Ability to facilitate small group meetings
  • Intermediate Other Ability to remain calm under pressure
  • Intermediate Other Ability to concentrate for extended periods on specfic 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

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Last Updated On: 12/9/2015