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.         

Essential Functions:

• Reviews and responds to written provider disputes, clearly and articulately outlining the payment discrepancy to the provider.
• Thoroughly researches post payment claims and takes appropriate action to resolve identified issues within turnaround time requirements and quality standards.
• Navigate CMS and State specific websites, as well as AMA guidelines, and compare to current payment policy configuration in order to resolve the providers payment discrepancy.
• Review medical records to ensure coding is consistent with the services billed and compares against the clinical coding guidelines in order to decide if a claim adjustment is necessary.
• Processes claim adjustment requests in Xcelys following all established adjustment and claim processing guidelines.
• Utilize SharePoint and Excel as necessary to work through daily inventory assignments.
• Identifies and escalates root cause issues to supervisor for escalated review.
• Reviews and responds to internal escalated provider disputes transferred by management and other associates.

Candidate Education:

• Required A High School or GED

Candidate Experience:

• Required 3 years of experience in claim coding, claim processing or billing in a healthcare environment
• Preferred 1 year of experience in claims coding

All your information will be kept confidential according to EEO guidelines.