Ensures accurate and timely loading of the Institutional/ASC or professional provider contracts. Oversees the maintenance and termination processes through appropriate research.
Department: Ops-Config Production
Reports to: Supervisor, Configuration
Location: W. Idlewild Ave., Tampa, FL 33634
Loads all institutional or professional contracts into the Diamond System through appropriate research and provider data load activities.
Performs accurate and timely provider research, verification and analysis.
Resolves provider load issues within established documented processes.
Ensures the proper supporting documentation exists and is maintained on file for all load processes.
Creates and updates payable procedure codes, price rules and fee schedules needed for Participating contracts.
Develop and maintain project plans for new business implementation (institutional only).
Researches both State & Federal mandates and builds State interpretation grids.
Creates and maintains price rules and fee schedules in coordination within State and Federal guidelines.
Monitors and tests the accuracy of price rules and fee schedules.
Create and maintain SATs as needed.
Resolves critical errors forwarded from the claims department.
Updates tracking database.
Builds and maintains positive business relationships with business partners.
Loads and maintains provider data.
Maintains high quality work.
Maintains productivity expectations.
Runs and manipulates data on Auto Analyzer Reports.
Reviews hospital or provider contracts to ensure they can be administered.
Communicates with Provider Relations when contracts can not be administered properly.
Assists in special projects
Education: High School Diploma requiredExperience: 2-4 years experience in health insurance required1 years experience in end to end configurationSpecial Skills (e.g. 2nd language): Strong understanding of contract terms and how they are loaded into the systemStrong understanding of provider maintenance and termination processesGood knowledge of institutional/provider billing practicesTechnical Skills/Requirements: Knowledge of Claims ProcessingKnowledge of CPT/HCPCS codingKnowledge of Access sufficient to pull queries related to provider loads, price rules, and claims processingKnowledge of Diamond and Cactus systemsIn-depth knowledge of Diamond provider/vendor files
About us Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.