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

Provider Resolution Specialist - Senior Job

Full Job Title: Provider Resolution Specialist, Sr.

Job Number: 1706276

Location: Tampa, FL

Date Posted: 1-9-2018

LOCATION: W. Idlewild Avenue, Tampa, FL 33634
DEPARTMENT: Operations – Provider Communications
REPORTING TO: Supervisor, Operations

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. Acts as a subject matter expert and handles more complex provider issues.

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 request in Peradigm Queue routing system and provides appropriate level of coaching, analysis and resolution to CSR or Provider.
  • Assists team members often guiding them to the appropriate resolution of more complex and difficult cases.
  • Identify root cause issues to ensure enterprise solutions and communicate findings as needed.
  • Utilize Customer service skills to create a high-quality customer experience, as reflected through Provider feedback, quality monitors and payment accuracy.
  • Assist in education of Providers as it relates to claims processing.
  • 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 Service 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 3 years of experience in a claims, customer service or health insurance environment
  • Preferred Other Previous experience in a healthcare environment
Candidate Skills:
  • Intermediate Demonstrated written communication skills
  • Intermediate Demonstrated interpersonal/verbal communication skills
  • Intermediate Ability to effectively present information and respond to questions from peers and management
  • Intermediate Ability to work as part of a team
  • 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