Claims Specialist III

Researches and processes institutional and professional claims. Provides subject matter expertise to departmental and corporate projects, analyzing and performing root cause analysis on all types of claims issues and adjustments. Serves as a primary point of contact to resolve issues requiring any and all other departments outside of 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.
  • Acts as Claims Department subject matter expert on departmental and corporate projects. Supports business definition and testing efforts, attends project meetings, maintains project plans and provides internal and external status reports.
  • Works with management and associates to document current business and workflow processes and collaborates in identifying, defining and documenting process improvement options and alternatives.
  • Researches complex claims issues and works with other departments to resolve. Serves as primary liaison to all external departments, markets, and providers on claims related content.
  • Analyzes and trends claims issues, performs true root cause analysis and determines next steps for resolution and process improvement.
  • Researches issues, compiles feedback and drafts corresponding business requirements documents and business decision documents as needed.
  • Communicates changes in processes, project status and issue resolutions through email, memos, group presentations, and/or individual one-off meetings.
  • Runs and analyzes ad-hoc reports.
  • Performs new hire audits.
  • Performs special projects as assigned.
Additional Responsibilities:
  • Arizona representatives may provide provider phone coverage two days a week
Candidate Education:
  • Required A High School or GED
Candidate Experience:
  • Required 3 years of experience in Previous claims or health insurance (for external candidates)
  • Required 2 years of experience in Claims with a solid understanding of internal claims functions, and have performed at least 5 of the duties found in the Claims III role (found in job description) - for internal candidates
Candidate Skills:
  • Advanced Ability to communicate and make recommendations to upper management
  • Advanced Ability to effectively present information and respond to questions from peers and management
  • Advanced Ability to multi-task
  • Advanced Ability to work in a fast paced environment with changing priorities
  • Advanced Ability to work independently
  • Advanced Demonstrated analytical skills
  • Advanced Demonstrated ability to deal with confidential information
  • Advanced Demonstrated customer service skills
  • Advanced Demonstrated interpersonal/verbal communication skills
  • Advanced Demonstrated organizational skills
  • Advanced Demonstrated problem solving skills
  • Advanced Demonstrated time management and priority setting skills
  • Advanced Demonstrated written communication skills
  • Advanced Knowledge of healthcare delivery
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
    • Required Intermediate Microsoft PowerPoint

      About us
      Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. 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.