Operations Lead - Grievances

Responds to member, provider and regulatory agencies’ inquiries and escalations (phone, written, or walk in) regarding all aspects of WellCare business within Operations in a professional, timely, accurate manner while consistently meeting all regulatory guidelines. Coaching and training new team members in addition to veteran associates. Serves in a limited leadership capacity as a subject-matter-expert, mentor and coach.

Reports To: Manager, Customer Service

Department: Operations

Position Location: Houston, TX 77081



Essential Functions:

  • Responds to basic member, provider and other inquiries via telephone, correspondence or lobby walk-in while meeting all corporate guidelines and performance standards.
  • Acts as a primary contact for escalated calls and/or escalated issues in which special care is required to enhance WellCare relationships with members and providers.
  • Acts as a mentor to associates. Provides real-time feedback as appropriate for the job function.
  • Acts as a Subject Matter Expert (SME).
  • Works with department management to maintain daily workflow within the department in order to maximize productivity. Assists in the development of long-range goals and drives through to completion.
  • Handles issues that require additional research and/or special handling including regulatory, congressional, trust, marketing, sales, executive office, Centers for Medicare and Medicare Services (CMS), etc.
  • Investigates problems of an unusual nature in the area of responsibility in order to identify root cause. Presents proposed solutions in a clear and concise manner.
  • Logs, tracks, follows-up and appropriately documents all issues utilizing on-line systems and procedures, and in accordance with all applicable guidelines and requirements.
  • Acts as a liaison between internal departments on data gathering and problem solving.
  • Works with external organizations (i.e., Social Security Administration (SSA) and CMS) to help resolve member and provider problems.
  • Drives and supports WellCare initiatives at the team by interacting with peers and other internal and external business partners while demonstrating a willingness to conform to WellCare policies and procedures.
  • Assists in the education of new members or providers and in the re-education of existing members or providers regarding health plan procedures.
  • Demonstrates expertise within all assigned LOB’s.
  • Performs skills necessary to create a high-quality customer experience, as reflected through acceptable C-Sat scores, quality monitors and member feedback.
  • Logs, tracks, resolve and responds to state regulators and market inquiries.
  • Assists with other projects and duties as assigned.
  • Performs production related work as necessary.
Additional Responsibilities:
    Candidate Education:
    • Required A High School or GED
    • Preferred An Associate's Degree in a related field
    • Preferred or equivalent work experience
    Candidate Experience:
    • Required 3 years of experience in a related field based on Operational area
    • Preferred Other Previous experience in a healthcare environment
    Candidate Skills:
    • Intermediate Ability to effectively present information and respond to questions from families, members, and providers
    • Intermediate Demonstrated interpersonal/verbal communication skills
    • Intermediate Ability to create, review and interpret treatment plans
    • Intermediate Other Ability to read, analyze and interpret verbal and written instructions
    • Intermediate Other Ability to write business correspondence
    • Intermediate Other Ability to apply sound judgment and decision-making skills in dealing with a variety of routine and non-routine issues
    • Intermediate Other Seeks to build trust, respect and credibility with all partners through full, honest, consistent, and coordinated communication
    Licenses and Certifications:
    A license in one of the following is required:
    • Preferred Other Customer service, quality or training certifications
    Technical Skills:
    • Required Intermediate Microsoft Outlook
    • Required Intermediate Microsoft Excel
    • Required Intermediate Microsoft Word
    • Required Intermediate Other Proficiency with all WellCare Based Systems utilized in job-function
    Languages:
    • Preferred Other Other 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. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. 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.