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Research and resolve all escalations from Members and Providers, as well as complaints coming from other escalated areas such as MET, Grievances, Compliance, Vendors, Appeals, Utilization Management and other areas for final resolution. These complaints include auth-related issues directed to CEO and ELT. The Intake Escalation Specialist team is the highest level of escalation for the authorizations department and handles issues related to all Lines of Business and Authorization Types.
Resolve the most highly escalated issues coming from other escalated areas such as MET, Grievances, Compliance, Vendors, Appeals, Utilization Management and other areas for final resolution.
Makes escalated, outbound phone calls to follow up on issues submitted by various teams to ensure timely resolution.
Receives urgent, inbound calls from providers and other departments to help fast-track resolution of issues.
Logs, tracks, resolves and responds to all assigned inquires and complaints from members, providers, governing bodies, Regulatory Agencies, Social Media, WellCare Legal Department, Corporate Compliance TRUST Department, Agency for Healthcare Administration (AHCA), while meeting all regulatory, AHCA and WellCare Corporate guidelines in which special care is required to enhance WellCare's relationships; while meeting and exceeding all performance standards.
Subject Matter Expert in all lines of business and auth types.
Effectively handle/resolve highly escalated issues and represent the Provider CCS/Authorizations Department in responding to these complaints in a professional manner seeking a win/win for all parties while respecting sound business and health management practices.
Assist in the education of level 1 agents, providers and other departments regarding current processes and procedures.
Thoroughly research and effectively communicate with our providers regarding the resolution of their inquiries, complaints and issues with a professional demeanor in a clear, articulate, and timely manner while demonstrating a strong understanding of the issues.
Work with providers to correct billing and claim issues with respective departments and educate providers about how to eliminate those problems going forward.
Act as a liaison between internal departments and external partners on data gathering and problem solving while investigating problems of an unusual nature in the area of responsibility. Present proposed solutions in a clear and concise manner.
Identify trends and monitors the root cause of member/provider issues and work cross functionally with different departments to ensure enterprise-wide solutions.
Enter authorizations or make updates to authorizations received via phone, fax, census or other channels
Perform other duties as assigned.
Required A High School or GED
Preferred An Associate's Degree in a related field
Required 2 years of experience in customer service experience in a healthcare contact center or customer service environment dealing with claims, grievances pharmacy and appeals authorizations in one or more of the following: Medicare, Medicaid, PDP, Exchange etc...
Required 1 year of experience in managing escalated complaints
Preferred 2 years of experience in managing various authorization modalities
Advanced Ability to effectively present information and respond to questions from peers and management
Advanced Ability to effectively present information and respond to questions from families, members, and providers
Advanced Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
Beginner Ability to implement process improvements
Advanced Ability to multi-task
Advanced Ability to work as part of a team
Advanced Ability to work in a fast paced environment with changing priorities
Advanced Ability to work independently
Advanced Demonstrated ability to deal with confidential information
Intermediate Demonstrated analytical skills
Advanced Demonstrated customer service skills
Intermediate Demonstrated problem solving skills
Intermediate Demonstrated written communication skills
Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-10 coding
Intermediate Demonstrated interpersonal/verbal communication skills
Licenses and Certifications: A license in one of the following is required:
Preferred Other Customer Service, Quality, or Training Certifications