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Research and resolve all escalations from members/providers that have been addressed to WellCare's Executive Offices, Executive Leadership Team or the CEO (Presidential) as well as complaints coming from other escalated areas such as MET, Grievances, and other areas for final resolution. The Service Escalation Unit (SEU) team is the highest level of escalation and handles issues for all lines of business (Medicare, Medicaid, PDP & Exchange).
Resolve the most highly escalated issues coming from other escalated areas such as MET, Grievances, and other areas for final resolution. The SEU team is the highest level of escalation.
Take escalated inbound/outbound phone calls on behalf of our Executive Leadership Team for all lines of business while maintaining the highest standard of quality on every call. (Calls are monitored for Quality and Training purposes.)
Logs, tracks, resolves and responds to all assigned inquires and complaints from members, providers, governing bodies, Regulatory Agencies, Better Business Bureau, Social Media, WellCare Legal Department, Corporate Compliance TRUST Department, Agency for Healthcare Administration (AHCA) and Florida Healthy Kids in writing and/or by telephone, while meeting all regulatory, AHCA and WellCare Corporate guidelines in which special care is required to enhance WellCare's relationships; while meeting and exceeding all performance standards.
Subject Matter Expert in all lines of business.
Effectively handle/resolve highly escalated issues and represent our CEO in responding to these complaints in a professional manner seeking a win/win for all parties while respecting sound business and health management practices.
Assist in the education of new members and in the re-education of existing members regarding health plan procedures.
Thoroughly research and effectively communicate with our members regarding the resolution of their inquiries, complaints and issues with a professional demeanor in a clear, articulate, and timely manner while demonstrating a strong understanding of the issues.
Work with providers to correct billing and claim issues and educate providers about how to eliminate those problems going forward.
Act as a liaison between internal departments and external partners on data gathering and problem solving while investigating problems of an unusual nature in the area of responsibility. Present proposed solutions in a clear and concise manner.
Identify trends and monitor the root cause of member/provider issues and work cross functionally with different departments to ensure enterprise wide solutions.
Perform other duties as assigned.
Additional Responsibilities:Candidate Education:
Required A High School or GED
Preferred Other Associate's or Bachelor's degree in related field
Required 3 years of experience in a healthcare Contact Center or Customer Service environment handling escalated complaints involving one or more of the following Lines of Business: Medicare, Medicaid, PDP, Exchange, etc.
Advanced Demonstrated written communication skills
Advanced Demonstrated interpersonal/verbal communication skills
Advanced Ability to multi-task Ability to multi-task, good organizational and time management skills
Advanced Demonstrated organizational skills
Advanced Demonstrated time management and priority setting skills
Advanced Ability to effectively present information and respond to questions from families, members, and providers
Advanced Demonstrated analytical skills Ability to read, analyze and interpret verbal and written instructions
Advanced Other Ability to work with people from diverse backgrounds
Advanced Other Ability to act on feedback provided by showing ownership of his or her own development
Advanced Other Ability to define problems collects data, establish facts and draw valid conclusions
Advanced 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