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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: 1806234

Location: Tampa, FL

Date Posted: 2018-08-28

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.

Essential Functions:
  • 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
Additional Responsibilities:
    Candidate Education:
    • Required A High School or GED
    • Required or equivalent work experience
    Candidate 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.
    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 Other Ability to follow direction
    Licenses and Certifications:
    A license in one of the following is required:
      Technical Skills:
        Languages:

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          Last Updated On: 12/9/2015