Remote Quality Retention Specialist (Required to work PST hours and live in North Carolina)

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Quality Retention Specialist supports our members in their disenrollment requests and related quality assurance. Acts in a customer-focused manner and is genuinely interested in the needs of our members. Address’ various customer-related needs and be able to problem-solve and effectively resolve call escalations.

GENERAL DUTIES/RESPONSIBILITIES (MAY INCLUDE BUT ARE NOT LIMITED TO):
1.    Serves as a “subject matter expert” in escalated member calls at risk of disenrollment and be able to resolve these escalations based on level of understanding/experience of healthcare, processes and protocols (i.e. authorizations, claims, provider network issues).
2.    Identifies process improvement opportunities within the Member Engagement department given the collaboration with different departments.
3.    Responsible for meeting and exceeding monthly goals as assigned.
4.    Acts as a subject matter expert in procedures, protocols, benefits, services, and any other necessary information to resolve member issues and inquiries.
5.    Conducts outbound phone calls and/or receiving inbound phone calls within the department’s goal timeframe; successfully contact and adapt to the member’s communication preferences as possible, which may include time of day, channel, and language; multi-lingual skills and/or utilize interpreter service as needed.
6.    Collaborates with our partners – including but not limited to other departments, supplemental benefit vendors, and provider networks – to facilitate the member experience.
7.    Shares best practices and participating in team meetings or training as required.
8.    Provides outbound support for PCP/IPA terminations. 
9.    Ensures that information and assistance provided is within the standards established by all applicable federal/state laws and regulations and health plan compliance. 
10.    Responsible for real-time documentation and timely wrap-up to support outcomes reporting in all systems/applications as required; must enter member demographics and information with accuracy and attention to detail and ensure high quality of our organizational data.
11.    Participates in required team meetings and trainings, and exhibit satisfactory understanding of new information and process related to the company, health plan benefit packages, and Centers for Medicare and Medicaid Services (CMS)
12.    Assists with the development and training of new hires including shadowing.
13.    Supports other projects and duties as assigned.

Minimum Requirements:

Experience:

Required:

• 1+ year of healthcare experience.
• 1+ year experience with Medi-Cal, Commercial, and Medicare Managed Care Plans and/or Sales, Customer Service, or Membership and Eligibility.

Preferred: Experience helping members navigate access to care through Medicare Advantage or HMO, including referrals and authorizations, medical prescription drug, and supplemental benefits preferred.

Education:

Required:

• High School Diploma or GED.  
• Bachelor's degree or four years additional experience in lieu of education.

Preferred: MBA

Specialized Skills:

• Required:

• Solid knowledge and understanding of the Medicare Managed Care Manual Chapter 2 - Medicare Advantage Enrollment and Disenrollment and Medicare Communications and Marketing Guidelines.
• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
• Ability to troubleshoot/problem solve.
• Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.
• Mathematical Skills: Ability to add and subtract two-digit numbers and to multiply and divide with 10’s and 100’s. Ability to perform these operations using units of American money and weight measurement, volume, and distance.
• Reasoning Skills: Ability to apply common sense understanding to carry out detailed, but un-involved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
• Problem-Solving Skills:  Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.

Preferred: Bilingual in one of the following Spanish, Vietnamese, Mandarin, Cantonese, or Korean

Licensure:

Required: None

Preferred: Sales License or completion of Alignment Health Plan sales certification a plus.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $38,569.00 - $57,853.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].