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Director Payment Integrity 

adzuna-us  |  United States  |  

United StatesSelden St, MI, 48201
Work Type:
Work Time:
Full Time


Join us at WellCare to build a better career while helping our members lead better, healthier lives.

Our leaders have a strong passion and a clear mission at WellCare.

Wherever you work within the organization, you will know that you are part of a larger, noble mission, dedicated to enhancing our members´┐Ż health and quality of life.

Here, you will find a culture of empowerment, teamwork and commitment as we all work together to deliver cost-effective solutions that create positive outcomes for our more than 6.0 million members.

LOCATION: 1 Campus Martius, Detroit, MI DEPARTMENT: Ops-Claims REPORTING TO: VP, Payment Integrity Directs corporate-wide overpayment recovery for medical and pharmacy expenses that include management of metrics, inventory management, performance management of staff, reporting, as well as vendor relationships.

Also, oversees other post-payment activity such as claims coding and data reconciliation.

Essential Functions: Directs identification and pursuit overpayments and TPL avoidance across all business lines for both medical and pharmacy fee for service expenses.

Directs cost benefits analysis to determine if the functions and activities required to identify, pursue and post overpayments should be internal or outsourced.

Directs the distribution and monitors standards such as turn around time, production and quality to managers of analytical and operational staff.

Directly develops business plans and sets financial targets to achieve desired goals.

Reviews and directs multiple units performance to enhance financial operations in support of medical cost reduction.

Directs the deployment of staff and technology to capture, prepare, analyze, maintain and distribute data necessary to maximize all recovery and reconciliation efforts.

Oversees and directs all vendor relationships specific to recovery activity.

Directs management in the development and implementation of policies and procedures that safeguard the company against fraud and overpayments.

Responsible for Claims Coding team including the inventory management of technical claims coding disputes against SLA's.

Responsible for providing oversight to the Data Reconciliation team inventory, inclusive of returned checks (including root-cause), check tracers, and also supporting regulatory audits.

Candidate Education: Required A Bachelor's Degree in a related field Required or equivalent work experience 4 additional years of claims payment and/or recovery activities Candidate Experience: Required 7 years of experience in Health care claims experience and/or recovery activities Required 4 years of management experience In managed care or insurance industry experience Candidate Skills: Intermediate Demonstrated leadership skills Intermediate Other Motivation skills Advanced Other Knowledge of capitation arrangements, coordination of benefits, subrogation and recoveries Technical Skills: Required Advanced Microsoft Excel Required Advanced Microsoft Access Required Advanced Microsoft Word Required Advanced Microsoft PowerPoint Required Advanced Other Knowledge of related databases About us Headquartered in Tampa, Fla., WellCare Health Plans, Inc.

(NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace.

WellCare serves approximately 5.5 million members nationwide as of September 30, 2018.

WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine.

For more information about WellCare, please visit the company's website at

EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies.

Comprehensive Health Management, Inc.

is an equal opportunity employer, M/F/D/V/SO.