Dec 06, 2019
WellCare Health Plans Efficiently and accurately conducts the intake of all incoming documents including but not limited to Member and Provider Coverage Determinations, as well as re-routing possible Duplicates and Appeals. Determines appropriate classification of each request, performs research and accurate data entry, as well as conducts initial processing and assignment of the requests. Essential Functions: Utilizes multiple systems to gather information, conduct research using different data sources to assess the situation, and enter data. Needs to access and interpret coverage determinations, appeals, and miscellaneous items. Conducts intake and appropriate classification of Coverage Determinations Requests, Redetermination requests. Makes accurate judgment on coverage determinations, medical records or other issues and follows procedures on how to handle each type of request and route to the appropriate area within the enterprise. Electronically enters request detail information in organization applications or specified work flow tool and documents other noteworthy aspects of the cases in the application. Evaluates data input and output for accuracy and ensures compliance with data integrity and corporate compliance directives. Completes data entry of all enterprise requests in an environment where compliance and accuracy are critical. Ensures timely processing and review of documentation to meet departmental goals and state specific benchmarks for timeliness. Answers / conducts inbound and outbound calls with members and provider offices to provide resolution to claims (i.e.: additional information requests and medication determination updates). Performs special duties as assigned. Additional Responsibilities: Candidate Education: Required A High School or GED Candidate Experience: Required 1 year of experience in Claims, Customer Service, Appeals, Pharmacy, Front End, Configuration or Enrollment, Data Capture role, preferably in a health services environment. Candidate Skills: Intermediate Demonstrated written communication skills Intermediate Demonstrated interpersonal/verbal communication skills Intermediate Ability to analyze and interpret financial data in order to coordinate the preparation of financial records Intermediate Ability to work as part of a team Intermediate Other Ability to review correspondence and system data to determine appropriate handling consistent with applicable policies and procedures. Licenses and Certifications: A license in one of the following is required: Technical Skills: Required Beginner Microsoft Outlook Required Beginner Microsoft Excel Required Beginner Microsoft Word Preferred Intermediate Other Ability to work across multiple computer programs to process a single request Preferred Intermediate Other Proficient in data entry Languages: About us Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. WellCare is a Fortune 500 company that employs nearly 9,000 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, sex, age forty (40) and over, disability, veteran status, or national origin.
Professional Diversity Network Detroit, MI, USA Full-Time