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
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
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
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
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: