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Clinical Policy Reimbursement Specialist

Wellcare - Tampa, FL

Clinical Policy Reimbursement Specialist','1706097','!*!About WellCare: WellCare Health Plans, Inc. is a Fortune 500 company traded on the New York Stock Exchange (symbol: WCG). It provides managed care services targeted to government-sponsored health care programs, including Medicaid, Medicare, Prescription Drug Plans and the Health Insurance Marketplace. Headquartered in Tampa, Fla., WellCare offers a variety of health plans for families, children, and the aged, blind and disabled. The company serves approximately 4 million members and employs approximately 6,500 people nationwide as of Sept. 30, 2014. For more information about WellCare, please visit our website at or view our videos at All qualified applicants shall receive consideration for employment without regard to race, color, religion, sex, age forty (40) and over, disability, veteran status, or national origin.','!*!Location: Henderson Rd, Tampa, FL 33634Department: Health ServicesReports to: Sr. Director, Strategic InitiativesPosition reviews and audits clinical information (medical claims) to determine appropriateness of charges in accordance with contracted payor terms, standards of care and Medicare/Medicaid requirements. Works with internal and external partners (physicians, members, payors and other healthcare providers) in support of appropriate utilization and timely reimbursement of healthcare services. Essential Functions:

Evaluates medical claims and/or medical records by applying clinical expertise to assess appropriateness of service provided, length of stay and level of care. Identifies and refers all cases not meeting medical necessity criteria and guidelines to appropriate decision maker for review.

Identifies and reports quality of care issues.

Evaluates and intervenes as needed for level of care, denial and compliance issues.

Identifies and refers members with special needs to the appropriate Wellcare Healthcare program per policy/protocol.

Assists with Complex Claim review; requires decision making pertinent to clinical experience.

Documents clinical review summaries, bill audit findings and audit details in the system.

Provides supporting documentation for denial and modification of payment decisions. ','!*!Candidate Education:

Required: Bachelor's Degree in nursing; or equivalent work experienceCandidate Experience:

Required: 3 years of experience in nursing (Critical care, ER, pediatrics, surgical setting, or related)

Required: 2 years of experience in utilization management or medical claims reviewCandidate Skills:

Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions

Ability to work as part of a team

Ability to work in a fast paced environment with changing priorities

Ability to work independently

Demonstrated analytical skills

Demonstrated problem solving skills

Demonstrated written communication skills

Knowledge of medical terminology and/or experience with CPT and ICD-10 coding

Knowledge of Milliman or InterQual guidelines Licenses and Certifications:A license in one of the following is required:

Required: Registered Nurse (RN)

Preferred: Coding Certification Technical Skills:

Microsoft Excel

Microsoft Outlook

Microsoft Word

Healthcare Management Systems','US-FL-Tampa','8735 Henderson Rd','','Tampa','33634','','','No','No','Clinical Policy Reimbursement Specialist'

7 days 16 hours ago



Clinical Policy Reimbursement Specialist Wellcare - Tampa, FL, United States


Location: Tampa, FL

Company Profile:
WellCare Health Plans, Inc. focuses exclusively on providing government-sponsored managed care services, primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, to families, children, seniors and individuals with complex medical needs. The company served approximately 3.8 million members nationwide as of Sept. 30, 2015. For more information about WellCare, please review our website and view the company’s videos. WellCare has developed a full complement of expertise in three major areas of government-sponsored health care…. Medicaid, Medicare Advantage and Medicare Prescription Drug Plans. Leveraging our expertise for our members' benefit is a key part of the value we bring to our members. WellCare focuses on those members who are dually eligible for both Medicaid and Medicare. This is an area of specialization that many other health plans simply do not have. We are committed to continually improving the quality of care and service that we provide to our members. We help our members access the right care at the right time in the appropriate setting. For some members, this includes the use of coordinated care teams and community partnerships. And we’re focused on government customers and use a disciplined approach to ensure a competitive cost structure.