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Provider Relations-Networking-Contracting WellCare - Provider Administration & Support Careers

Provider Resolution Specialist Job

Full Job Title: Provider Resolution Specialist

Job Number: 1800222

Location: Cypress, CA

Date Posted: 1-9-2018

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


Essential Functions:
  • 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
Candidate Education:
  • Required A High School or GED or equivalent work experience
Candidate 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.
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 Ability to follow direction

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Last Updated On: 12/9/2015