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.
- 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.
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)
Special Skills (e.g. 2nd language):
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
Proficiency with Microsoft Outlook to easily and readily communicate with both internal and external contacts
Proficiency with Word and/or Excel sufficient to easily and readily manipulate data