Jul 31, 2019

Operations Quality Auditor

  • Professional Diversity Network
  • Kapolei, HI, USA
Full-Time Facilities

Job Description

WellCare Health Plans

Perform compliance quality audits on all Inbound and Outbound teams including teams with casework in Operations and Enrollment. Assist in the development of QA strategies on policies, procedures and systems to accurately measure and report areas of improvement. Manage turn-around times to ensure compliant with business requirements. Participate in any internal compliance or external CMS audit or state audit. Assist in the development of trending issues. Recommend training improvement changes. Perform random Shopper Test Calls and Root Cause Analysis on Operational areas to ensure accuracy of departmental processes and identify, when needed, process improvement opportunities.

Department: Operations

Report To: Supervisor Operations

Location: Kapolei, HI

Essential Functions:

  • Conduct daily quality reviews on associate calls, enrollment files and/or casework in accordance with WellCare's quality policy
  • Review casework (CTM, Grievance) and call documentation for thoroughness, and accuracy of information while meeting compliance turn-around-times in accordance with WellCare Policy and Procedure and any government (Federal or State) processes
  • Summarize and communicate to management audit results on a regular schedule
  • Assist with team training and attend calibration
  • Identify trends, prioritize and recommend improvement in documentation and call handling.
  • Assist in review of all CMS audits, internal or external state audits. Identify training opportunities, individual and team coaching needs and reports findings to senior management.
  • Develop and present ideas for performance and process improvement within the department
  • Acts as subject matter expert (SME)
  • Assist with other projects and duties as assigned
Additional Responsibilities:

Candidate Education:

  • High School or GED (required)
  • Bachelor's Degree (preferred)
Candidate Experience:
  • 3 years of experience in Customer Service related position (or 2 years WellCare experience) Required
  • 2 years of experience in directly related audit work
  • Other Healthcare experience
Candidate Skills:
  • Ability to multi-task
  • Ability to work in a fast paced environment with changing priorities
  • Ability to remain calm under pressure
  • Ability to sit for extended periods of time
  • Demonstrated technical expertise in performing quality reviews along with analysis of results

Licenses and Certifications:
A license in one of the following is required:

Technical Skills:

  • Required Intermediate Microsoft Outlook
  • Required Intermediate Microsoft Word
  • Preferred Intermediate Microsoft Excel
  • Preferred Intermediate Microsoft PowerPoint
  • Preferred Intermediate Other Knowledge of additional software programs as necessary

About us
Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.



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