LOCATION: W. Idlewild Avenue, Tampa, FL 33634
DEPARTMENT: Operations – EDI Ops
REPORTING TO: Manager, Operations
Responsible for working with providers to set up and maintain electronic transactions including electronic data interchange (EDI); electronic fund transfers (EFT) and other web site services. Performs quality audits of multiple vendors to assess compliance with WellCare's contractual and regulatory requirements. Serves as liaison to WellCare's providers, vendors and internal departments involving electronic and paper submission of provider and member correspondence. Performs root cause analysis of issues associated with electronic and paper submission.
Additional Responsibilities:Candidate Education:
- Effectively communicate with provider community, vendor(s) and internal departments to provide quality responses via phone and email on electronic data issues to support Customer Service Tool (CMR).
- Perform "root cause" analysis on identified electronic and paper submission issues.
- Work with vendors to build positive business relationships and provide quality resolution in a timely manner.
- Analyze reports to identify issues such as incorrect electronic submission and incorrect routing of paper correspondence.
- Coordinate provider issues with appropriate internal departments, performs accurate and timely provider research, verification and quality analysis.
- Analyzes data to evaluate operational difficulties and makes recommendations to solve problems.
- Assists with special projects.
- Performs analysis and tests systems and improve outcomes/accuracy.
- Conducts daily, weekly and monthly quality audits ensuring accuracy across multiple systems.
- Tracks trends and issues, validates with in-depth data and analysis; applies quality solutions in a timely manner.
- Comply with federal, state and HIPAA regulations.
- Work with internal IT EDI/HIPAA Trading Partner Coordinator for testing and development.
- Audit vendor outputs to ensure SLA compliance and accuracy standards.
- Effectively communicate with provider and market community and provide quality responses via phone and email on electronic data issues to support the EDI-Master email inbox.
- Analyze electronic formats (837I and 837P).
- Maintains an understanding of department processes in order to research and identify improvement opportunities.
- Tracks and maintains quality results for appropriate distribution.
- Performs other duties as assigned.
- Effectively communicate with internal departments and provide quality responses on mail quality emails.
- Utilizes tools and resources in order to provide quality responses to providers, internal departments, and the market.
- Required A High School or GED
- Preferred An Associate's Degree in a related field
- Required 1 year of experience in directly relevant work. Customer Service and/or EDI environment (health insurance preferred)
Licenses and Certifications:
- Advanced Demonstrated written communication skills
- Advanced Demonstrated interpersonal/verbal communication skills
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- Intermediate Demonstrated analytical skills
- Intermediate Other Ability to define problems collects data, establish facts, and draw valid conclusions
- Intermediate Other Ability to apply sound judgment and decision-making skills in dealing with a variety of routine and non-routine issues, often with limited standardization
A license in one of the following is required:
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft PowerPoint