Provider Resolution Specialist

Position is primarily responsible for answering escalated claim adjustment requests and resolving issues received through transferred provider phone calls, customer service management and miscellaneous special project work.

Essential Functions:
  • Answers CSR claim inquiries via live transfer and resolves issues real time
  • Thoroughly researches post payment claims and takes appropriate action to resolve them within turnaround time requirements and quality standards
  • Acts as a liaison between internal departments on data gathering and problem solving while investigating problems of an unusual nature in the area of responsibility. Presents proposed solutions in a clear and concise manner.
  • Processes claim adjustment and provide appropriate level of coaching, analysis and resolution to CSR or Provider.
  • Identify root cause issues to ensure enterprise solutions and communicate findings as needed.
  • Evaluate and report financial payment accuracy on claims processors.
  • Process reports to improve informational resources.
  • Assist in education of Providers as it relates to claims processing.
  • Log, track and document all issues utilizing online systems and procedures, and in accordance with all applicable guidelines and requirement while on call with Providers.
  • Utilize Customer services skills to create a high-quality customer experience, as reflected through Provider feedback, quality monitors and payment accuracy.
  • Resolve critical errors as it relates to rejections, coding denials, claims processing and pricing.
  • Adhere to call metric and handle times to ensure in meeting services level goals are met.
  • Assists with special projects as assigned or directed
Additional Responsibilities:
    Candidate Education:
    • Required A High School or GED
    • Required or equivalent work experience
    Candidate Experience:
    • Required 1 year of experience in previous claims or health insurance
    • Required Other or 9 months to 1 year experience at WellCare as a Sr CSR or Sr. Claims Specialist.
    Candidate Skills:
    • Intermediate Demonstrated written communication skills
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Intermediate Ability to work as part of a team
    • Intermediate Ability to effectively present information and respond to questions from peers and management
    • Intermediate Other Ability to follow direction
    Licenses and Certifications:
    A license in one of the following is required:
      Technical Skills:
        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.