Complaints Coordinator - MetroPlusHealth

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The Complaints Coordinator provides comprehensive customer service to members, providers, and prospective members. The primary responsibilities include but are not limited to documenting all customer contacts into the tracking system, process complaints, assisting supervisory staff with complaints review, handle escalated issues and assist the management team with specialty projects.

• Perform reviews of complaints and correctly determine and enter complaint review results per the regulatory requirements for Complaints.
• Have a full understanding of the complaint handling process from initiation/acknowledgement to closure/resolution.
• Create complaint reports and enter initial complaint log details
• Inform appropriate members of the management team about patterns in complaints that are averse to the plan.
• Utilize other experts as needed to ensure clear understanding / investigation of applicable issues
• Perform complaint related investigations
• Investigate complaint details to determine root cause
• Complete a Complaint Summary report of complaints being worked on and identify if Corrective / Preventive Action is required
• Process and close complaints in a timely manner
• Update complaint log with closure details
• Assist specialist with escalated issues: i.e., transportation requests, specialty appointments
• Assist management staff with special projects: i.e., PCP monthly projects (IT-Assignments, PCP error reports)
• Record and respond to all Customer contacts and update in tracking system. Manage and ensure appropriate follow-up and closure for all customer contacts
• Provide on-site as well as telephone orientations to new and existing members
• Process and resolve complaints and record given information in the system
• Assist members with the selection and assignment of PCP’s
• Update all member demographic changes
• Provide all benefit/service-related information to members, perspective members and providers
• Perform retention efforts for all lines of business
• Assist with the handling of overflow Medicare calls, special projects, and outreach projects
• Handle roster Inquiries
• Handle disenrollment inquiries from members, providers and regulatory agencies
• Handle provider inquiries
• Respond to all claim billing inquiries from providers and members.
• All other duties and special assignments as assigned by the Complaints Supervisor and Manager

• Bachelor’s degree required; and
• 1 year of relevant call center experience including experience with reviewing/resolving complaints; or
• A satisfactory equivalent combination of education, training, and experience.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication

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