Medicare Sales Operations Specialist - Sr. Job Listing at Medical Mutual in OH (Job ID 2400549)

Description

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.6 million Ohioans through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.   

Medical Mutual' s status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us and help our members achieve their best possible health and quality of life.   

Medicare Sales Operations Specialist

Executes all end-to-end functions relating to the investigation of sales violations and complaints to the Medicare Advantage Sales Compliance area issued via Appeals and Grievances (A/G), the Complaint Tracking Module (CTM) and other internal sources. Works with multiple departments to execute the investigation process, gather facts from internal and external sources, issue corrective action plans and make sound decisions to remediate the agent and/or process gaps. Maintains agent oversight of Medicare field sales and marketing events, marketing communications and other fulfillment needs identified for the business area.

Sr. Medicare Sales Operations Specialist

Executes end-to-end functions relating to sales administration and oversight of the Company's Medicare products. Oversees annual agent certification training, ongoing sales compliance training, agent compensation protocols, and ongoing First Tier, Down Stream, & Related Entity (FDR) oversight and monitoring. Partners with cross-functional areas to execute processes previously identified in order to meet and achieve compliance with regulatory requirements.

Responsibilities 

Medicare Sales Operations Specialist

• Manages receipt, tracking and status of identified sales investigations.  Maintains database and logs for regulatory reporting.
• Reviews the issue, applies Chapter 3 logic (Medicare Marketing Guidelines) to verify sales allegation. Determines if violation is a marketing misrepresentation or process breakdown.  Works with sales management channels to execute investigations and follow up tasks.
• Determines the root cause of the sales violation in order to issue a Corrective Action Plan (CAP) for agent remediation.  Works with the respective sales management to guide and direct the CAP.
• Trends MA sales violations in order to identify process breakdowns. Presents solutions to deter violations.
• Oversees Agent of Record (AOR) and agent referral protocols. Reviews the AOR request and form, ensuring agent appointment/licensure, and authorizes agent referral compensation based on contractual term acceptance and deliverables. Maintains tracking system for audit purposes.
• Provides on-site, face-to-face agent oversight of Centers for Medicare/Medicaid Services (CMS) filed events – both informal and formal sales and marketing activities. Reports any identified deficiencies and provides onsite agent coaching.
• Coordinates secret shopper program and Compliance Management Portal (CMP) vendor contracts.  Audits services received and ensured payment of invoices.
• Maintains departmental policy and procedures and related workflows.
• Performs other duties as assigned.

Sr. Medicare Sales Operations Specialist

• Executes annual agent certification training, which includes planning, staging testing, soft launch testing and final output. Oversees training content, secures audit trail reporting standards, and collaborates with vendor and IT partners to prepare training and audit deliverables.
• Provides guidance on the Field Marketing Organization (FMO) assessment program protocols for effective sales monitoring prior to contract execution. Revises scoring methodology to ensure alignment with FMO contract obligations. Ensures the sales agent works with FMO partners on corrective action plans and remediation of identified deficiencies to bring them to optimal operating standards. 
• Executes onsite FDR monitoring, secret shopping of agent activities, vendor oversight and enhances employed and captive agent onboarding. Monitors vendor contracts addressing any potential deficiencies and executes Corrective Action Plans (CAPs) were applicable for the delegated functions.
• Oversees Agent of Record (AOR) administration processes and provides payment approvals. Governs agent appointment and ongoing certification, annual Schedule A and Centers for Medicare/Medicaid Services (CMS) agent rate filings, and continual FMO/agent/agency training through established channels.
• Oversees sales/marketing incident management that involves CAPs where process improvement identification to deter future violations will be required.
• Provides sales/marketing content material review and pre-approval prior to CMS filing, and agent job aid and Medicare event pre-approval for our all sales distribution channels. 
• Performs other duties as assigned.

Qualifications

Medicare Sales Operations Specialist

Education and Experience

• Bachelor's degree in Business Administration, Healthcare Administration or related field or equivalent combination of training and experience.
• 3 years of experience with government health insurance programs which includes exposure to Medicare Advantage, MA compliance protocols, member experience, agent experience, case investigation and/or equivalent relevant experience.

Professional Certification(s):

• Ohio Department of Insurance (ODI) Accident and Health Insurance License highly desirable (otherwise required to obtain within 4 months of hire).
• Certified in the Company's Medicare Advantage products a plus (otherwise required to obtain 30 days post state licensure issuance.

Technical Skills and Knowledge:

• Knowledge of Centers for Medicare/Medicaid Services (CMS) Medicare sales and marketing regulations and guidelines including Ohio Department of Insurance agent licensing requirements.
• Knowledge of health insurance products and services and standard industry practices.    
• Knowledge of Medicare Advantage plans (MA, MAPD).
• Intermediate to advanced Microsoft Office skills (Word, Excel, Outlook, PowerPoint).

Sr. Medicare Sales Operations Specialist

Education and Experience

• Bachelor's Degree in Business Administration, Management, Marketing and/or related field or an equivalent combination of education/training and experience.
• 5 years of experience in Medicare sales compliance or equivalent experience with government health insurance programs which includes exposure to Medicare Advantage, MA compliance protocols, member experience, agent/broker sales experience, and sales/marketing case investigations.

Professional Certification(s):

• Ohio Department of Insurance (ODI) Accident and Health Insurance license (otherwise required to obtain within 4 months of hire).
• Certified in the Company's Medicare Advantage products a plus (otherwise required to obtain 30 days post state licensure issuance).
• America's Health Insurance Plans (AHIP) or Gorman Health Group's CMS Training Certification (or ability to obtain within one month).

Technical Skills and Knowledge:

• Comprehensive knowledge of Medicare health care products and services, sales operations and standard industry practices. Ability to identify gaps in operations processes, provide remediation, and hold applicable FDR entities accountable.
• Comprehensive knowledge of Centers for Medicare/Medicaid Services (CMS) Medicare sales and marketing regulations and guidelines including Ohio Department of Insurance agent licensing requirements.
• Strong vendor management and project management skills.
• Intermediate to advanced Microsoft Office skills (Word, Excel, Outlook, PowerPoint, Visio).

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:

A Great Place to Work:

• We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
• Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
• On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
• Discounts at many places in and around town, just for being a Medical Mutual team member.
• The opportunity to earn cash rewards for shopping with our customers.
• Business casual attire, including jeans.

Excellent Benefits and Compensation:

• Employee bonus program.
• 401(k) with company match up to 4% and an additional company contribution.
• Health Savings Account with a company matching contribution.
• Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.
• Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
• Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
• After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

An Investment in You:

• Career development programs and classes.
• Mentoring and coaching to help you advance in your career.
• Tuition reimbursement up to $5,250 per year, the IRS maximum.
• Diverse, inclusive and welcoming culture with Business Resource Groups.

About Medical Mutual:

Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.

There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.

We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.

At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.