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Corporate Functions & Operations WellCare - Appeals & Grievances Careers

Grievance Coordinator - Senior Job

Full Job Title: Grievance Coordinator, Sr

Job Number: 1706184

Location: Houston, TX

Date Posted: 12-19-2017

Responds to member and provider inquiries (phone, written or walk in) regarding all aspects of WellCare business, including claims and pharmacy, in a professional, timely, accurate and caring manner while consistently meeting all state specific guidelines and requirements. Serves in a limited leadership capacity as a subject-matter-expert and mentor.
Essential Functions:
  • Responds to basic member, provider and other inquiries via telephone, correspondence or lobby walk-in while meeting all corporate, state and regulatory 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.
  • Handles calls 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. Presents proposed solutions in a clear and concise manner.
  • Acts as a liaison between internal departments on data gathering and problem solving.
  • Drives and supports WellCare initiatives at the team level by interacting with peers and other internal and external business partners while demonstrating a willingness to conform to WellCare policies and procedures.
  • Demonstrates appropriate customer-care skills such as empathy, active listening, courtesy, politeness, helpfulness, and other skills as identified.
  • Records, investigates and resolves customer complaints as detailed in the Grievance Procedure narrative.
  • Assist in the education of new members and in the re-education of existing members regarding health plan procedures.
  • Coordinate the review of grievances to include preparing the case with all relevant documentation, scheduling the case processing the review conducted by the department's consultant
  • Interact with other departments including Appeals, Claims, Provider Relations, Pharmacy, 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 within all assigned LOB's. Handles calls for multiple LOB's as assigned.
  • Performs skills necessary to create a high-quality customer experience, as reflected through acceptable Quality scores.
  • Develop and present ideas for performance and process management improvement within the department.
  • Acts as a Subject Matter Expert (SME).
  • Assists with other projects and duties as assigned.
Education:
  • High School Diploma required; Associate Degree preferred.
Experience:
  • 3 years experience within a call center or customer service environment
  • 1-3 years Grievance experience preferred
  • Experience within a health care company preferred
Licenses/Certifications:
  • Customer service, quality, or training certifications (preferred)
Skills:
  • Strong written and verbal communication skills and an ability to work with people from diverse backgrounds
  • Ability to multi-task, good organizational and time management skills
  • Ability to act on feedback provided by showing ownership of his or her own development
  • Ability to read, analyze and interpret verbal and written instructions
  • Ability to write business correspondence
  • Ability to effectively present information and respond to questions from members
  • Ability to define problems collects data, establish facts and draw valid conclusions
  • Seeks to build trust, respect and credibility with all partners through full, honest, consistent, and coordinated communication
Technical Skills/Requirements:
  • Proficiency working with Microsoft Word, Excel and Outlook

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Last Updated On: 12/9/2015