Claims Specialist II

Researches and processes institutional and professional claims. Serves as a mentor to less experienced associates and acts as a resource to resolve more complex claims.

Essential Functions:
  • Processes claims that pend for various hold reasons to assist in the final determination on claim disposition.
  • Processes adjustments related to projects or provider disputes providing timely follow-up provider call backs.
  • Researches complex claims issues and works with all external departments, markets, and providers on claims related content.
  • Completes new hire audits.
  • Runs and analyzes ad-hoc reports.
  • Identify root-cause issues to ensure enterprise solutions and communicate findings as needed.
  • Participates in all formal and informal training opportunities.
  • Assists with special projects as assigned or directed.
Additional Responsibilities:
  • Arizona representatives may provide provider phone coverage two days a week
Candidate Education:
  • Required A High School or GED
Candidate Experience:
  • Required 2 years of experience in Previous claims or health insurance (for external candidates)
  • Required 6 months of experience in Institutional and / or professional claims
Candidate Skills:
  • Intermediate Ability to communicate and make recommendations to upper management
  • Intermediate Ability to multi-task
  • Intermediate Ability to work independently
  • Intermediate Ability to work in a fast paced environment with changing priorities
  • Intermediate Demonstrated analytical skills
  • Intermediate Demonstrated customer service skills
  • Intermediate Demonstrated organizational skills
  • Intermediate Demonstrated time management and priority setting skills
  • Intermediate Demonstrated written communication skills
  • Intermediate Demonstrated interpersonal/verbal communication skills
  • Intermediate Demonstrated problem solving skills
Licenses and Certifications:
A license in one of the following is required:
    Technical Skills:
    • Required Intermediate Microsoft Outlook
    • Required Intermediate Microsoft Word
    • Required Intermediate Microsoft Excel
    Languages:

      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 www.wellcare.com. 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.