Works with sales management and corporate offices to identify real time abrasion/disenrollment potentials. Identifies areas of process breakdown and potential disenrollment to help build provider and member retention strategies based on detailed data analysis on Claims, Customer/Provider Service and Enrollment. Maintains a database of member problems and performs root cause analysis to suggest operational improvements to prevent similar issues from recurring. Functions as member advocate while still respecting sound business and health management practices.
Department: Sales - Medicare
Reports to: Sr Mgr, Sales Operations
Additional Responsibilities:Candidate Education:
- Works with members to amicably resolve issues and problems in a way that encourages those members to remain loyal to WellCare.
- Works with providers to correct billing and claims issues and educates providers about how to eliminate those problems going forward.
- Analyzes reports such as claims denial and front-end reject reason codes to determine appropriateness and areas of intervention.
- Determines specifications for ad-hoc reports needed for key abrasion/retention efforts and summarizes accordingly.
- Analyzes daily call contact reports to determine accuracy, follow-up, timeframes and possible disenrollment threats.
- Contacts members at risk for disenrollment based on report analysis and act as an elevated resolution team.
- Identifies additional areas of clarification needed for members and providers based on call contact reports and claims reporting.
- Monitors, analyzes and reports information from outsource vendors for disenrollment survey information.
- Communicates weekly with sales management regarding key areas of member and provider abrasion for tracking and trending.
- Analyzes grievance report data to determine trends and training needs and adherence to state reporting guidelines.
- Works with sales management on the maintenance of Sharepoint communication documents, banner messages, automatic email updates, and compliance alerts.
- Performs other duties as assigned.
- Required An Associate's Degree in a related field
- Preferred A Bachelor's Degree in a related field
- Required 3 years of experience in claims processing, customer service, reimbursement methodologies and/or member retention
- Preferred 1 year of experience in data, financial and reporting collection and analysis
- Preferred Other managed care or government program experience
Licenses and Certifications:
- Beginner Demonstrated analytical skills
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- Intermediate Ability to effectively present information and respond to questions from peers and management
- Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Intermediate Ability to proof large bodies of materials
- Intermediate Demonstrated organizational skills
- Beginner Demonstrated project management skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Beginner Demonstrated written communication skills
- Intermediate Ability to multi-task
- Intermediate Demonstrated customer service skills
- Intermediate Knowledge of healthcare delivery
A license in one of the following is required:
- Preferred Licensed 2-40 Health Insurance
- Required Beginner Microsoft Project
- Required Beginner Microsoft Access
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Outlook
- Required Intermediate Microsoft PowerPoint
- Required Intermediate Microsoft Excel
- Required Intermediate Other Familiarity with reporting tools (Crystal, Discovery, etc.)
- Preferred Intermediate Other Experience with HSD Diamond managed care system