Operations Quality Auditor

Perform compliance quality audits on all Inbound and Outbound teams including teams with casework in Operations and Enrollment. Assist in the development of QA strategies on policies, procedures and systems to accurately measure and report areas of improvement. Manage turn-around times to ensure compliant with business requirements. Participate in any internal compliance or external CMS audit or state audit. Assist in the development of trending issues. Recommend training improvement changes. Perform random Shopper Test Calls and Root Cause Analysis on Operational areas to ensure accuracy of departmental processes and identify, when needed, process improvement opportunities.

Essential Functions:
  • Conduct daily quality reviews on associate calls, enrollment files and/or casework in accordance with WellCare's quality policy
  • Review casework (CTM, Grievance) and call documentation for thoroughness, and accuracy of information while meeting compliance turn-around-times in accordance with WellCare Policy and Procedure and any government (Federal or State) processes
  • Summarize and communicate to management audit results on a regular schedule
  • Assist with team training and attend calibration
  • Identify trends, prioritize and recommend improvement in documentation and call handling.
  • Assist in review of all CMS audits, internal or external state audits. Identify training opportunities, individual and team coaching needs and reports findings to senior management.
  • Develop and present ideas for performance and process improvement within the department
  • Acts as subject matter expert (SME)
  • Assist with other projects and duties as assigned

Department: Ops- Quality

Level: L07

Reports To: Supv, Ops

Additional Responsibilities:

    Candidate Education:
    • Required A High School or GED
    • Preferred A Bachelor's Degree in a related field
    Candidate Experience:
    • Required 3 years of experience in Customer Service related position (or 2 years WellCare experience)
    • Preferred 2 years of experience in directly related audit work
    • Preferred Other Healthcare experience
    Candidate Skills:
    • Intermediate Ability to multi-task
    • Intermediate Ability to work in a fast paced environment with changing priorities
    • Intermediate Other Ability to remain calm under pressure
    • Intermediate Other Ability to sit for extended periods of time
    • Intermediate Other Demonstrated technical expertise in performing quality reviews along with analysis of results
    Licenses and Certifications:
    A license in one of the following is required:
      Technical Skills:
      • Required Intermediate Microsoft Outlook
      • Required Intermediate Microsoft Word
      • Preferred Intermediate Microsoft Excel
      • Preferred Intermediate Microsoft PowerPoint
      • Preferred Intermediate Other Knowledge of additional software programs as necessary
      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.