Job Details

Bil Rate ***
Everyone has to clear to start for 6.1.26 for trainig purposes

Job Purpose:
This position is responsible for receipt and coordination of CMS MA-PD and PDP escalated complaints; submission of member and marketing materials to CMS for HCSC's Medicare Advantage and Prescription Drug Plans; applying CMS regulations pertaining to Medicare Advantage and Prescription Drug Plans to the review of member and marketing materials prior to submission to CMS; providing assistance and guidance regarding Medicare Advantage and Prescription Drug Plan regulations to HISC staff; working with other areas of the organization on the development, testing and implementation of organization, process and system changes to ensure the requirements of the Medicare Advantage and Prescription Drug program are met; and assisting MCO in coordination of the contract with CMS enterprise-wide.

Job Responsibilities:
• Thoroughly Investigate, resolve, and clearly document all CTM issues with priority to urgent and immediate need CMS requests, special cases and management requests from start to finish within the required timeframe.
• Follow departmental policies and procedures and federal regulatory requirements when making decisions on member impact, compliance, and other implications.
• Assist with new hire onboarding and training activity.
• Back up to other team members who are out of the office or take on additional workload to ensure timely case closure.
• Conduct peer-to-peer quality reviews, identify gaps and deficiencies, provide feedback and opportunities for improvement.
• Identify system issues causing increased complaints and suggest improvements to prevent future occurrences.
• Provide recommendations and collaborate with leaders and business partners in operating efficiencies.
• Facilitate meetings with cross-functional business partners, as necessary, to properly address complex cases.
• Provide expertise in triaging escalated sensitive/high risk issues from receipt to resolution.
• Participate in weekend coverage rotation.
• Serve as a super user for MHK/system testing.
• Use critical thinking and problem-solving skills to identify root causes and adequate remediation of cases.
• Collect information from cross-functional areas, consolidate, and strategically and carefully use judgment when preparing CMS case summaries and responses.
• Work in conjunction with functional areas to review and improve methods, develop workflow, determine operational processes, and system enhancements to reduce administrative expenses.
• Directly make updates to the CMS tool - HPMS.
• Knows the formal and informal departmental goals, standards, policies and procedures, which includes familiarity of other departments within the organization that allows him/her to identify workflow efficiencies and process improvements across the organization.
• Displays a positive attitude and escalates problems and issues to management as appropriate.
• Ability to exercise administrative judgment and assumes responsibility for decisions, consequences, and results that have an impact on people, costs, and/or quality of service within the functional area.
• Handles other duties and special projects as assigned.
Knowledge, Skills, Abilities Required:
• Extensive knowledge of CTM team processes and Medicare MAPD and PDP guidelines.
• Ability to work a flexible work schedule that may include Saturday as a normal workday or a holiday weekend on a rotating basis.
• Excellent verbal and written communication skills, as well as, listening and conflict resolution skills.
• Ability to affectively adapt and respond in a complex, fast-paced, high-volume environment.
• Ability to maintain positive/productive relationships.
• Ability to exercise administrative judgment and assumes responsibility for decisions, consequences, and results that have an impact on people, costs, and/or quality of service within the functional area.
• Basic understanding of managed care and its place in the health care industry.
• Highly organized and can work independently.
• Strong interpersonal skills and the ability to communicate with many different levels of staff.
• Ability to identify and analyze problems and recommend solutions.
• Proficiency with analytical tools, knowledge of data analysis methodology, strong communication skills and strong commitment to and affinity for delivering the highest level of customer service.
• Continuous improvement mindset-identify process gaps and improvement opportunities.

Required Job Qualifications:
• Bachelor's degree preferred or 4+ years of experience in Medicare Advantage and PDP plans.
• Knowledge in Medicare regulatory requirements.
• Proficiency in CMS systems preferred and Microsoft Office (Excel, Word, Outlook).
• Strong verbal and written communication skills.
• Strong critical thinking and analytical abilities to address complex issues.
• Experience in the areas of customer service, grievances, and appeals highly preferred.
• Proficiency with analytical tools, knowledge of data analysis methodology, strong communication skills and strong commitment to and affinity for delivering the highest level of customer service.
• Ability to work a flexible work schedule that may include Saturday as a normal workday or a holiday weekend on a rotating basis.

Computer Skills:
Proficient in Microsoft Office including Outlook, Word, Excel, and PowerPoint.

Preferred Job Qualifications:
Bilingual preferred.

EEO:

"Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of - Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans."