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Operations Account Specialist at WellCare in Cypress, California

Posted in General Business 30+ days ago.

Type: Full-Time

Job Description:

Coordinates and documents provider inquiries. Researches and assists Operations Account Representatives with resolution of claims inquiries for the Medicare and Medicaid lines of business regarding reimbursement issues, health plan payment methods, benefit coordination and eligibility/enrollment operations.


Report to: Senior Manager, Ops Account Management

Department: Ops-National Account Management

Location: Cypress, CA 90630

Essential Functions:

  • Serves as primary intake point for all provider issues and logs all provider inquiries.

  • Supports the Operations Account Representatives to resolve claims and payment issues.

  • Applies a comprehensive knowledge of claims processing, provider contracts and contract configuration to escalated provider inquiries.

  • Thoroughly researches escalated issues and takes appropriate action to resolve them within established service level agreements, WellCare best practice and quality standards.
  • Complies with all corporate and Provider operations policies, procedures and workflows.
  • Performs other projects as assigned

Additional Responsibilities:


Candidate Education:

  • Required A High School or GED

  • Preferred A Bachelor's Degree in a related field Bachelor's degree may be substituted for 2 years of required experience

Candidate Experience:

  • Required 2+ years of experience in researching and resolving operational issues.

  • Preferred Other experience in a healthcare environment with technical proficiency in Claims, Configuration or Operations with experience working with claims data and inaccurate payments

Candidate Skills:

  • Intermediate Knowledge of healthcare delivery

  • Advanced Demonstrated analytical skills

  • Intermediate Demonstrated organizational skills

  • Intermediate Demonstrated problem solving skills

  • Ability to analyze and interpret financial data in order to coordinate the preparation of financial records

  • Intermediate Demonstrated time management and priority setting skills

  • Intermediate Demonstrated interpersonal/verbal communication skills

  • Intermediate Demonstrated written communication skills

  • Intermediate Other Ability to understand, interpret and communicate provider contracts,

  • Intermediate Other Ability to understand, interpret and communicate Medicare and Medicaid contracts

  • Intermediate Other Ability to understand regulatory guidance as it relates to provider reimbursement

  • Intermediate Other Ability to follow direction

  • Intermediate Other Strong critical thinking skills

  • Intermediate Other Proficiency with professional claims, configuration and/or provider contracts

Licenses and Certifications:
A license in one of the following is required:
    Technical Skills:

    • Preferred Beginner Microsoft Access

    • Required Intermediate Microsoft Excel

    • Required Intermediate Microsoft Outlook

    • Required Intermediate Microsoft Word

    • Preferred Intermediate Microsoft PowerPoint