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Corporate Functions & Operations WellCare - Claims Careers

Claims FWA & Reporting Analyst - C1 Job

Full Job Title: Claims FWA & Reporting Analyst - C1

Job Number: 1806114

Location: Phoenix, AZ

Date Posted: 2018-08-17

Reviews daily, weekly, and monthly reports to ensure accurate claims processing prior to adjudication. Performs data analysis and review and approval of FW&A recommendations prior to adjudication. Serves as a subject matter expert on claims adjudication for the Medicaid and Medicare lines of business within the health plan.

Department: Ops, Claims

Report To: Mgr, Strategic Operations

Location: Phoenix, AZ 85016



Essential Functions:

  • Handles all claims reports, encounter reversals and E-Status claims review within designated timeframes.
  • Reviews, analyzes and makes final acceptance of FW&A recommendations within 24-business hours of response file from FW&A vendor.
  • Reviews monthly reports for identification of system enhancements and process changes to ensure accurate adjudication on a go-forward basis.
  • Completes daily reports promptly and efficiently, identifying training opportunities, documentation needs, and system updates to minimize future instances.
  • Proactively identifies adjustment sources in order to minimize the volume of claims that require secondary handling, generating ideas and creating solutions to improve or simplify procedures, techniques, and processes.
  • Researches, reviews and accurately adjudicates CMS-1500 and UB claims of all levels of complexity, correcting claims prior to adjudication.
  • Tracks and trends claims processing issues related to auto-adjudication and employee handling of claims, and assists Claims Department in identifying and quantifying issues along with reviewing Claims Department work processes as requested.
  • Identifies and assists in conducting additional claims training needed for internal staff as needed.
  • Perform other duties as assigned.
Additional Responsibilities:
    Candidate Education:
    • Required A High School or GED
    • Preferred An Associate's Degree in a related field
    Candidate Experience:
    • Required 3 years of experience in claims processing including COB/TPL and claim reversals and adjustments.
    • Required 1 year of experience in MHC claims processing
    Candidate Skills:
    • Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
    • Intermediate Demonstrated analytical skills
    • Intermediate Demonstrated problem solving skills
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Intermediate Ability to multi-task
    • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
    • Intermediate Ability to work in a fast paced environment with changing priorities
    • Intermediate Demonstrated organizational skills
    • Intermediate Ability to work independently
    • Intermediate Demonstrated written communication skills
    • Intermediate Ability to effectively present information and respond to questions from peers and management
    • Intermediate Other Attention to detail with high level of accuracy
    • Beginner Other Basic knowledge of procedures used in fraud, abuse and waste detection and investigation
    • Intermediate Other Knowledgeable in AHCCCS and CMS rules/regulations/reference tools/policy manuals, etc.
    • Intermediate Other Detailed understanding of claims processing of institutional and/or professional claims
    Licenses and Certifications:
    A license in one of the following is required:
      Technical Skills:
      • Required Intermediate Microsoft Excel
      • Required Beginner Microsoft Word
      • Required Beginner Microsoft Outlook
      Languages:
      • Preferred English

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      Last Updated On: 12/9/2015