Responsible for working with providers to set up and maintain electronic transactions including electronic data interchange (EDI); electronic fund transfers (EFT) and other web site services. Support or lead various processes or process improvements such as: paper to electronic (P2E) claim conversion, Business Rule Performance (EDI-Gateway, CIS, DCR and Core Processing System/Xcelys), Organize process changes with the vendors, building test claims and completing test cycles. Serves as liaison to WellCare's providers, vendors and internal departments concerning the claim life-cycle from the EDI Gateway up to data consumption within the Core Processing System (CPS).
Communicate with provider community via phone and email for connectivity and rejection edit data issues.
Work with electronic vendors for quick issue resolution, builds and maintains positive business relationships with business partners.
Support increased Encounters Acceptance Rates via reject analysis leading to inbound claim edits.
Support EDI Rate increases/Reduced Paper Submissions.
Direct Data Entry Tool Maintenance.
Lead or Support Provider Manual creation and maintenance as well as ad-hoc Provider Communication.
Run reports and analyze data to identify providers not submitting electronically or providers submitting incorrectly.
Act as subject matter expert by providing technical assistance and guidance to management and associates on operational issues, process changes and activity status.
Coordinate provider issues with appropriate internal departments, performs accurate and timely provider research, verification and analysis.
Collects and analyzes data to evaluate operational difficulties and makes recommendations to solve problems.
Compile Weekly and Monthly management reports.
Create and maintain work process flows and documentation via SharePoint.
Creates training and marketing material for provider community and other departments such as Provider Relations and Customer Service.
May also assist in preparing various reports that cover forecast reports, budget status, and other management related reports.
Assist is system requirements gathering and testing to ensure accuracy across multiple systems.
Collects data and performs analysis and tests systems and improve outcomes/accuracy.
Assist in the development and maintenance of various policies and procedures effecting the operations of the department.
Work with internal IT EDI/HIPAA Trading Partner Coordinator for testing and development.
Works on EDI help desk queue.
Analyze and edit electronic formats.
Set up and lead audits on vendor outputs to ensure SLA compliance and accuracy standards.
Performs other duties as assigned.
Required A High School or GED
Preferred An Associate's Degree in a related field
Required 3 years of experience in directly relevant experience. Customer Service and/or EDI environment (health insurance preferred)
Advanced Demonstrated written communication skills
Advanced Demonstrated interpersonal/verbal communication skills
Intermediate Ability to effectively present information and respond to questions from families, members, and providers
Intermediate Demonstrated analytical skills Ability to read, analyzes, and interprets verbal and written instructions.
Intermediate Other Ability to define problems collects data, establish facts, and draw valid conclusions
Intermediate Other Ability to apply sound judgment and decision-making skills in dealing with a variety of routine and non-routine issues, often with limited standardization
Licenses and Certifications: A license in one of the following is required: Technical Skills:
Required Intermediate Microsoft Excel
Required Intermediate Microsoft Word
Required Intermediate Microsoft PowerPoint
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.