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
- 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
- Required 2 years of experience in direct claims processing or provider configuration
- 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:
- 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