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Claims Audit Specialist

WellCare – Tampa, FL

Independently performs end to end audits of Operational area to ensure accuracy of departmental processes as they trace back to source and identify (if necessary) process improvement opportunities.
Department: Operations Reports To: Manager, Claims Audit Location: Tampa, FL 33634
Essential Functions:
  • Conducts daily quality reviews of operations department processes (i.e. eligibility, enrollment, claims processing and pricing, configuration contract loads, etc).
  • Responds to first and second level rebuttals in a timely manner.
  • Tracks and maintains quality results for appropriate distribution.
  • Communicates audit results in a structured report format.
  • Identifies and quantifies issues and recommend audit criteria to validate financial impact.
  • Navigates audit tools and prepares ad hoc reports using Microsoft Excel or Access to summarize audit findings.
  • Assists with identification and communication of process improvement opportunities across operation area s based on quality audit reviews.
  • Assists with special projects and 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 2 years of experience in direct claims processing or provider configuration
Candidate Skills:
  • Advanced Knowledge of healthcare delivery Strrong functional knowledge of healthcare delivery
  • Intermediate Demonstrated interpersonal/verbal communication skills
  • Intermediate Ability to work independently
  • Intermediate Ability to work as part of a team
  • Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
  • Intermediate Ability to work in a fast paced environment with changing priorities
  • Intermediate Demonstrated time management and priority setting skills
  • Intermediate Demonstrated organizational skills
  • Intermediate Ability to multi-task
  • Intermediate Other Understanding of managed care and the health care industry in general
  • Intermediate Other Ability to understand and interpret contracts as related to claims processing or configuration
  • 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
  • Intermediate 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:

Technical Skills:
  • Required Intermediate Microsoft Excel Demonstrated technical expertise in performing quality reviews along with analysis of results
  • Required Intermediate Microsoft Outlook Knowledge of CPT/HCPCS Coding
  • Required Intermediate Microsoft Word Intermediate to Advanced knowledge of Microsoft office
  • Required Intermediate Microsoft PowerPoint
  • Required Intermediate Other Demonstrated technical expertise in performing quality reviews along with analysis of results
Languages:

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