Complaint Tracking Module Coordinator

  • location: Tampa, FL
  • type: Contract
  • salary: $18 per hour
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job description

Complaint Tracking Module Coordinator

job summary:
Description:

JOB SUMMARY

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 Company's Star Ratings.

ESSENTIAL FUNCTIONS

Note: The following is not intended to be an exhaustive list of all duties required of this position

Key Duties and Responsibilities

- 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 Company Medicare PDP, and CCP lines of business.

- Drives and supports Company 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 Company 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 Company 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 Position Responsibilities - Optional

MINIMUM QUALIFICATIONS

Education

State the minimum required for the job

Education Level Education Details Required/Preferred


A High School or GED Required

An Associate's Degree in a related field Preferred

A Bachelor's Degree in a related field Preferred

Work Experience

State the minimum required for the job

Experience Level Experience Details Required/Preferred

1+ year of experience in Contact Center and/or Customer Service Environment Required

1+ year of experience in Experience within a Healthcare company Preferred

1+ year of experience in CTM or Escalations Experience Preferred

Licenses and Certifications

List professional licenses and certifications associated with this job

Licenses/Certifications Other Licenses/Certifications Required/Preferred

Other Customer service, quality or training certifications Preferred

Skills

State the minimum required for the job

Skill Sets Other Skills Proficiency

Demonstrated written communication skills Advanced

Demonstrated interpersonal/verbal communication skills Advanced

Ability to multi-task 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 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 Intermediate

Technology

List technical skills associated with the job

Technology Other Technology Proficiency Required/Preferred

Microsoft Outlook Intermediate Required

Microsoft Word Intermediate Required

Microsoft Excel Intermediate Required

Microsoft PowerPoint Intermediate Preferred

SharePoint Intermediate Preferred

Xcelys Intermediate Preferred

Other HPMS, MARx Intermediate Preferred

Languages

List all that apply

Languages Other Languages Required/Preferred

Spanish Preferred

 
location: Tampa, Florida
job type: Contract
work hours: 8 to 5
education: High School
experience: 1 Years
 
responsibilities:
Description:

JOB SUMMARY

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 Company's Star Ratings.

ESSENTIAL FUNCTIONS

Note: The following is not intended to be an exhaustive list of all duties required of this position

Key Duties and Responsibilities

- 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 Company Medicare PDP, and CCP lines of business.

- Drives and supports Company 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 Company 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 Company 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.

 
qualifications:
Additional Position Responsibilities - Optional

MINIMUM QUALIFICATIONS

Education

State the minimum required for the job

Education Level Education Details Required/Preferred


A High School or GED Required

An Associate's Degree in a related field Preferred

A Bachelor's Degree in a related field Preferred

Work Experience

State the minimum required for the job

Experience Level Experience Details Required/Preferred

1+ year of experience in Contact Center and/or Customer Service Environment Required

1+ year of experience in Experience within a Healthcare company Preferred

1+ year of experience in CTM or Escalations Experience Preferred

Licenses and Certifications

List professional licenses and certifications associated with this job

Licenses/Certifications Other Licenses/Certifications Required/Preferred

Other Customer service, quality or training certifications Preferred

Skills

State the minimum required for the job

Skill Sets Other Skills Proficiency

Demonstrated written communication skills Advanced

Demonstrated interpersonal/verbal communication skills Advanced

Ability to multi-task 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 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 Intermediate

Technology

List technical skills associated with the job

Technology Other Technology Proficiency Required/Preferred

Microsoft Outlook Intermediate Required

Microsoft Word Intermediate Required

Microsoft Excel Intermediate Required

Microsoft PowerPoint Intermediate Preferred

SharePoint Intermediate Preferred

Xcelys Intermediate Preferred

Other HPMS, MARx Intermediate Preferred

Languages

List all that apply

Languages Other Languages Required/Preferred

Spanish Preferred

 
skills: Other
Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.

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