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Responds to member, provider, CMS, SPAP and SHIP inquiries received via phone, CTM (Complaint Tracking Module) and email regarding PDP, CCP and Medicaid lines of business, including Claims, CIU, Enrollment, Pharmacy, Billing, Case Management, and Appeals in a professional, timely, accurate and caring manner- while consistently meeting all CMS guidelines and requirements. Instrumental in providing suggestions to reduce complaints and increase WellCare's Star Ratings.
Responds to member, provider, CMS, SPAP and SHIP inquiries via telephone, CTM (Complaint Tracking Module) and email, while meeting all corporate, regulatory and CMS guidelines and performance standards. Independently evaluates and assesses allegations to determine those criteria, including federal and state regulations, Centers for Medicare & Medicaid Services ("CMS") guidelines, and internal policies, procedures, and standards that are alleged to have been violated.
Demonstrates appropriate customer-care skills such as empathy, active listening, courtesy, politeness, helpfulness, and other skills as identified. Assist in the education of new members and in the re-education of existing members regarding health plan procedures.
Records, investigates and resolves complaints as detailed in the CMS Standard Operating Procedures (SOP) and the CTM Policies and Procedures.
Investigates problems of an unusual nature in the area of responsibility. Presents proposed solutions in a clear and concise manner.
Identifies risks, interprets investigation results, and recommends and communicates remedial actions to mitigate future potential risks.
Thoroughly documents, organizes, and reviews case files electronically, relative to each investigation in accordance with Company policy and ensures remediation activities are implemented. Interact with other departments including Enrollment, Pharmacy, Billing, etc. to resolve member and provider issues.
Logs, tracks and follow-ups on all inquiries, utilizing on-line systems and procedures, according to the established guidelines.
Demonstrates expertise of all WellCare Medicare PDP, and CCP lines of business.
Drives and supports WellCare initiatives at the team level by interacting with peers and other internal and external business partners, such as RCA inquiries, Governance weekly meetings, Quality Audit calibrations, CMS Call Audits, and CSQIW/QIC while demonstrating a willingness to conform to WellCare policies and procedures.
Develops and presents ideas for performance and process management improvement within the department.
Supports the development and maintenance of Corporate Compliance policies and procedures and workflows.
Conducts and documents with beneficiaries, providers, interdepartmental investigatory purposes.
Acts as a primary contact for escalated calls and/or escalated issues in which special care is required to enhance WellCare relationships with members, providers, CMS Caseworkers, SPAPs and SHIPs.
Works on Good Cause Reinstatement cases and making sure members make full payment and are reinstated by our Enrollment Department within Medicare Guidelines.
Performs skills necessary to create a high-quality customer experience, as reflected through acceptable Quality scores.
Handles calls that require additional research and/or special handling- including regulatory, congressional, Swift, Press Hill, marketing, sales, executive office, Centers for Medicaid and Medicare Services (CMS), etc. Responsible for the intake and assignment of CTM complaints through HPMS/Inbound phone intake.
Additional Responsibilities:Candidate Education:
Required A High School or GED
Preferred An Associate's Degree in a related field
Preferred A Bachelor's Degree in a related field
Required 1 year of experience in Contact Center and/or Customer Service Environment
Preferred 1 year of experience in Experience within a Healthcare company
Preferred 1 year of experience in CTM or Escalations Experience
Advanced Demonstrated written communication skills
Advanced Demonstrated interpersonal/verbal communication skills
Intermediate Ability to multi-task Ability to multi-task, good organizational and time management skills
Intermediate Demonstrated organizational skills
Intermediate Demonstrated time management and priority setting skills
Intermediate Ability to effectively present information and respond to questions from families, members, and providers
Intermediate Demonstrated analytical skills Ability to read, analyzes, and interprets verbal and written instructions
Intermediate Other Ability to work with people from diverse backgrounds
Intermediate Other Ability to act on feedback provided by showing ownership of his or her own development
Intermediate Other Ability to define problems collects data, establish facts and draw valid conclusions
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