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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.
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
Required A High School or GED
Required or equivalent work 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.
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: