Operations Account Specialist

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.

Department: Operations

Reports To: Director, Ops Account Management

Location: Houston, TX

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

        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.