• To investigate all sales related complaints for agents and agencies including internal and external and report the findings back to the responsible area which could be internally or to CMS.
• Responsible for researching and/or investigating complex sales related complaints which include but not limited to MAPD, PDP, and could include CSB.
• Assist in training new Lead Analysts as they join the team on the end-to-end processes and functions of the department.
• Responsible for assigned caseload which requires timely follow up to ensure completion of cases within tight frames to meet internal and CMS expected goals.
• Demonstrates the ability to problem solve, identify root causes, and make the proper recommendations to correct the root cause of the issue/complaint.
• Makes outbound calls to gather information and/or communicate the resolution to the appropriated party regarding the member complaint.
• Creates written correspondence letters to provide resolution to complaints when verbal contact cannot be made with the complainant.
• Documents all case research notes and resolution actions, in the appropriate systems, within the required timeframes.
• Communicates with other departments, when necessary, to resolve member issues.
• 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 reports problems and issues to management as appropriate.
• Maintain professional knowledge of state and federal regulatory guidance, primarily the Medicare Communication and Marketing Guidelines to utilize in all functions, processes, and communications with agencies and business partners
• Perform other duties as assigned by Sales Integrity Leadership
• Manage, process, and document cases for the Sales Development Action Program and committees. The research findings are presented to the committee.
• Involved in routine oversight and ad hoc duties for the Sales Development Action Program (SDAP) and Complaint Investigation Process
• Responsible for sales support processes, including but not limited to complaint creation and submission, complaint tracking and reporting, CRM database updates and/or general sales support.
• Conduct a thorough investigation of complaints (CTMs, CSVs, etc.) and escalated inquiries from customers that complained to CMS, the local department of insurance Customer Service, etc.
• The position uses analytical skills, knowledge of CMS guidelines, scripts, MAPD/PDP benefit plans, provider tools, CRM and other company provided tools in determining if a violation actually occurred.
• Research and documentation are critical since it can affect not only the agent but the customer.
• Individual reports may be generated and analyzed in this research process to make recommendations and future actions in a proactive approach. Accurately resolve issues at hand and prevent future complaints from occurring.
• Subject matter expert for complaint related issues for both internal and external partners including Sales, Sales Operations, Sales Account Management, CARL Escalations, or Broker Strategist teams.
• Supports program development, maintenance activity and provides highly technical advice on regulatory issues
• Serve as resource for compliance-related issues and reporting
• Perform quality checks to ensure compliance with CMS.
• Perform ad hoc audits and projects for the department outside of normal duties
• Negotiate or resolve complex issues with customers, internal agents and/or external matrix partners using consistent independent judgement and discretion and being assertive when necessary
• Routinely coordinates data compilation requests, process communication updates and document maintenance projects
• Be honest and respectful in all dealings with internal and external partners
• Support 24/7 operation needs as required, including weekends

• High School Diploma required
• BA/BS or equivalent work experience 6+ years of experience in Medicare Advantage
• 5+ years of experience in regulatory/compliance, MAPD Sales, or other relevant work experience preferred
• Knowledge of CMS
• High attention to detail, quality, and accuracy
• Strong coordination and organizational skills
• Excellent verbal and written communication skills, as well as, listening and conflict resolution skills.
• 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.
• Fast-learner and multi-tasking skills
• Ability to work independently in a matrixed environment
• Strong interpersonal and prioritization skills
• Sales and/or training experience recommended
• Ability to handle multiple assignments, projects and deliverables simultaneously required
• Ability to work under pressure and flexible hours required.
• Weekend on call hours are required (as needed)

IRI-IT

Pulled from the full job description

• 401(k)
• Health insurance
• Dental insurance, * 401(k)
• Dental insurance
• Health insurance