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Corporate Functions & Operations WellCare - Claims Careers

Claims FWA & Reporting Analyst Job

Full Job Title: Claims FWA & Reporting Analyst

Job Number: 1802784

Location: Phoenix, AZ

Date Posted: 5-25-2018

This position is for Care1st Health Plan, a WellCare Healthplans, Inc. company.

Department: Operations Claims -Medicaid

Reports to: Operations Supervisor

Location: E. Camelback Rd, Phoenix AZ 85016

Job Type: Hourly/ Non-exempt

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.

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.
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

Technical Skills:
  • Required Intermediate Microsoft Excel
  • Required Beginner Microsoft Word
  • Required Beginner Microsoft Outlook


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Last Updated On: 12/9/2015