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.
Department:California – Operations State
Reports to:Sr Dir, State Operations
Location: 10803 Hope Street Suite B, Cypress, CA 90630
Job Type: Hourly/Non-exempt
- Answers Customer Service Representative (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
- Required A High School or GED or equivalent work experience
- Required 1 year of experience in previous claims or health insurance or 9 months to 1 year of experience at WellCare as a Sr CSR or Sr. Claims Specialist.
- 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 Ability to follow direction