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Appeals Intake Specialist (Columbia, MO)
at WellCare Health Plans
Columbia, MO

Appeals Intake Specialist (Columbia, MO)
at WellCare Health Plans
Columbia, MO

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Description

Efficiently and accurately conducts the intake of all incoming documents including but not limited to Member and Provider Appeals, as well as re-routing Grievances, Pharmacy, Claims Correspondence, etc., and related requests. Determines appropriate classification of each request, performs research and accurate data entry, as well as conducts initial processing and assignment of the requests. Performs duties related to root cause analysis of escalated issues involving member and provider Appeals.

REPORTS TO: MANAGER, APPEALS & GRIEVANCES
DEPARTMENT: PHS - APPEALS
POSITION LOCATION: COLUMBIA, MISSOURI 65201

Essential Functions:

  • Utilizes multiple systems to gather information, conduct research different data sources including Xcelys, WC Toolbox, Application Extender, Emma, Appeals Tracker, assess the situation, and enter data. Needs to access and interpret claim, appeal correspondence and authorization data.
  • Perform detailed root cause analysis to determine core issue related to member and/or provider complaint, error or inquiry.
  • Conducts intake and appropriate classification of Appeals, Grievances, Pharmacy, and Claims Correspondence etc. requests and makes accurate judgment on appeal, grievance, claim disputes, 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 claim detail information in organization applications including Sidewinder, Peradigm, databases or specified work flow tool and documents receipt, disposition and 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.
  • Performs special duties as assigned.
Additional Responsibilities:

Candidate Education:

  • Required A High School or GED
Candidate Experience:
  • Required 1 year of experience in a 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 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 Word
    • Required Beginner Microsoft Excel
    • Required Beginner Microsoft Outlook
    • Required Beginner Other Ability to work across multiple computer programs to process a single request
    • Required Beginner Other Proficient in data entry
    Languages:

      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.

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