PowerPoint Presentation

[Audio] Good day! Welcome and thank you for attending our Quality Session. We are excited to partner and work with all of you as we all strive for excellence and insanely great customer satisfaction!.

[Audio] Here is the agenda for our Quality Discussion. We can pause per agenda to answer questions or clarify grey areas. Our Quality team will be glad to entertain and answer your questions and clarifications. Let's get it on!.

[Audio] Now let's discuss what is Quality.. What is Quality?.

[Audio] As we start our Quality discussion. Let's define Quality. What is Quality? Quality is the standard of something as measured against other things of a similar kind; the degree of excellence of a something. It is also defined as the general excellence of standard or level. It is also the totality of features and characteristics of a product or service that bear on its ability to satisfy a given need. Quality involves meeting customers need preferences and exceeding it..

[Audio] For Alorica we have the Centralized Quality team. Our objective is for the team to follow a centralized approach on Quality to ensure that the below benefits are provided: Common methods and processes Impartial and objective results Ability to identify trends and/or best practices across the entire organization More sustainable infrastructure Operating units free to focus on their operations and external customer Our desired outcome is to provide a consistent unbiased approach for monitoring transactions and providing Operations with data required for coaching..

[Audio] Let's move on in discussing the specific evaluation requirements for Centene..

[Audio] Here are the evaluation requirements for Centene. Agents will receive a total of 8 audits per month though the numbers of audit may defer depending on the valid exceptions like leaves absences system issues and the likes. Our Quality team randomly select recorded calls and it should be a maximum of 72 hours old. Next evaluation should be after 48 hours to give time for coaching feedback. If the first transaction monitored is found to have no critical errors or receives an overall passing score there will be no restriction on when the second transaction will be monitored..

[Audio] The purpose of this presentation is to provide an understanding of the quality evaluation process. This document is not meant to be all-inclusive. Guidance may vary based on specific health plan or compliance requirements. Changes/updates to this document will be made throughout the year as necessary upon approval by executive leadership. These guidelines are in line with The Centers for Medicare and Medicaid Services (C-M-S--) Centene policies and procedures as well as processed documents all of which may need to be referenced from time to time to gain clarification regarding guidance contained herein..

[Audio] Each call is evaluated using 8 compliance scoring criteria and 18 customer experience scoring criteria. The compliance section will measure an agent's success with compliance driven requirements. Compliance requirements include but are not limited to Caller Identification Appeals and Grievance following appropriate work processes providing accurate information and providing the correct resolution. The customer Experience section consist of components that will measure the agent's success with their interaction and handling with the caller promoting a quality and great customer experience on each call. Each of the 26 scoring components have a point value. Passing score is 95% and above while below 95% is a failing score..

[Audio] Here are the equivalent score per Compliance line items which compose of the 70% of the quality score. On the next slides we will discuss what are the requirements and the most common opportunities per Compliance line item..

[Audio] C.1 Caller Identity Verification or commonly known as HIPAA. For this line item we need to correctly verify caller member/provider and any authorized personal representative. Adheres to P-H-I standards by refraining from releasing P-H-I to unauthorized caller We need to ensure that we verify: 1. Member's First and Last Name DoB Plan ID number or Medicare ID. 2. If member ID number is not available. Alternate verifier – Address and phone (These information must be provided by the member or caller).

[Audio] Here the common opportunities for Caller Identity Verification or HIPAA: Reading off the member's name on file prior to validating the account. Failed to verify the member ID. For a transferred call receiving agent failed to verify if the member was fully authenticated. Failed to verify the member address and phone number as an alternate verifier when member ID is not available. Released P-H-I to a T-P-C which is not listed as the Executor of the Estate..

[Audio] State Specific requirements is a line item ensuring we adhere to state specific requirements..

[Audio] C.3 Work process or accurate information. we need to utilize all available resources including previous call note and documentation based on caller needs. Follow all appropriate work process outlined in the CP articles and provide accurate information related to the members plan providing correct educational texts and disclaimers and advising of accurate information related to all caller inquiries..

[Audio] Here the common opportunities for Work Process and/or Accurate Information: Not checking previous ticket and/or document search. Call with no screen capture or video recording. Not reading/paraphrasing the required scripting and/or disclaimers. Not providing the timeframes due dates payment posting date CD approved date. Benefit stage tier level. Not running a price estimate. Not confirming the mailing address prior to completing a material request. Not providing/offering the phone number prior to transferring the call. Not offering the C-S-A-T survey. Not following the verification process (No P-H-I released).

[Audio] C.4 Access to Care. We should adhere to all established Access to care processes..

[Audio] C.5 Documentation. We should have a complete and accurate documentation based of what transcribed on the call. Using the correct call driver is a must. We also need to remember the following: Call notes will include the five Ws of the call – who what when where and why. The call notes will tell the story of why the member or provider called. The agent must fully document the call according to the relevant work process. Documentation must be completed during the call or immediately after completion of the call. Because documentation may be requested by the state or used as a legal record the agent must avoid abbreviations that may be confusing to someone outside of Centene..

[Audio] Here the common opportunities for Documentation: Not documenting the pertinent information provided by our member such as member concern. Not utilizing the call driver selecting correct the radio buttons. Not documenting S-S-O was offered. Not documenting copay deductible mediation name tier level due date when advised. Not creating a ticket..

[Audio] C.6 Call Activities. We need to handle the call properly and do not cause caller abrasion. Refrain from call avoidance and intentional disconnection and making disparaging remarks. Agents must avoid activities which prevent the agent from adequately assisting a caller. The expectation is for the agent to answer calls in a prompt and professional manner..

[Audio] Here the common opportunities for Call Activities: Agent lingered on the call for more that 5 seconds after a call has fully closed. Call riding. Stayed more than 10 seconds on other line after the call was warm transferred. Making negative comments about the program. Caller was placed on an excessive hold and then was cold transferred. Call avoidance or refusing to accept the transfer call. Intentional disconnection or placing the call on hold and press the end button..

[Audio] C.7 Appeals and Grievances. In this line item we need to correctly assisting the member in filing a grievance and appeal..

[Audio] The important step we need to complete to ensure we do not have a failed score in this line item to ensure we offer the member to file a grievance when the member expressed dissatisfaction frustration and inconvenience..

[Audio] C.8 Resolution. We must correctly assess the reason for the call and clearly separate and provide a resolution for each issue. Addressed any adjacent issues to avoid repeat calls. Things to Consider for Member calls: Does the work process followed produce a resolution for the member? Does the action taken reduce the member's effort in getting resolution? Does the resolution address most frequent adjacent issues i.e forward resolve additional issues to avoid repeat calls? Is there a proactive and transparent communication process to close the loop? Does the resolution reduce member uncertainty/instill confidence the issue is resolved?.

[Audio] Here are the common opportunities for Resolution: Failed to educate the member with Buzz Rx program. Referring the member to call Medicare when it was not specifically stated in the call flow. Not providing complete options to help the member with his copay and incase S-S-A will be denied they still have other options like Drug Manufacturer program SPAP is available in their State. Providing incorrect eligibility benefits and claim information. No F-C-R due to non-utilization of resources. Not transferring the call to E-S-I for further assistance. Failed to offer the member to file Coverage Determination over the phone..

[Audio] As we completed the Compliance line items now let us discuss the Customer Experience which is the remaining 30% of the Quality score. The customer Experience section consist of components that will measure the agent's success with their interaction and handling with the caller promoting a quality and great customer experience on each call. Here are the Customer Experience line items 1 to 8 that focuses on Customer Interaction..

[Audio] Here are the Customer Experience line items 9 to 16 focusing on Customer Handing..

[Audio] Here are some of the reminders for Customer Experience line items. CE.1 Agent demonstrated professionalism courtesy and respect. We should avoid verbal collisions Exceed on promised hold timeframe and failure to provide the timeframe prior on placing the caller on hold and failed to thank the caller after the hold. CE.2 Agent adhered to dead air guidelines. We must not exceed 30 seconds explained dead air and 10 seconds' unexplained dead air..

[Audio] CE. 3 Agent appropriately managed call and provided information in clear and efficient manner. Ensure the call is efficiently managed by keeping the call on task to assist the caller. Speak reasonably loud and clear where the caller can understand what the agent is saying. CE.4 Agent displayed active listening skills. Demonstrate active listening by being attentive to the customer's needs and does not ask the caller to repeat information the caller has just provided. Most common errors are Caller repeats information like D-O-B that has been clearly provided and Email address provided was clearly audible but agent asked the member to repeat it..

[Audio] CE.5 Agent was patient and responded to customer frustration appropriately. Express understanding and offered a statement acknowledging the inconvenience to the caller. CE.6 Agent showed empathy when appropriate. Be empathetic with the caller when appropriate. Show concern if the caller mentions an area of concern that displays hardship or frustration..

[Audio] CE.7 Agent developed rapport with caller and created a personalized experience. Utilizing the callers last name asking to address them by their first name relating to the members concern in an appropriate manner acknowledging the members birthday if approaching or just passed. CE.8 Agent utilized smooth transitions from one topic to the next making the caller feel at ease. Confirm the caller's issue has been resolved before transitioning to the next issue or concern..

[Audio] CE.9 Agent answered call within appropriate timeframe branded the call and provided name in the greeting. Answer the call with 5 seconds zip tone and greet the caller. Most common errors are failed to brand the call during opening and delayed greeting failing to answer the call withing 5 seconds after the zip tone. CE.10 Agent offered assistance acknowledged caller's issue and displayed a willingness to assist. Common miss is failing to use affirmative statement after determining what the caller needs..

[Audio] CE.11 Agent offered appropriate amount of alternatives and options and/or promoted self-service options relevant to call. We need to offer self-service options when appropriate during the call. CE.12 Agent used simple phrasing/re-aligned phrasing to promote understanding and avoided jargon. Use words or phrases the caller can easily understand and avoid using internal jargons like coverage check and IEUWG..

[Audio] CE.13 Agent asked appropriate questions to ensure understanding of the caller's issue if unclear. It is necessary to probe to ensure correct understanding of the caller's issue. CE.14 Agent ensured interaction was free from background noises and distractions. Ensure the interaction is free from avoidable background noises and distractions. For example loud music Television background et cetera.

[Audio] CE.15 – Agent offered the call reference number on all calls when applicable. Offering the call reference number to the caller when applicable. CE.16 – Agent closed the call with assurance of customer satisfaction (Validate caller received information with no additional questions). Agent thanked Caller and branded call with the specific plan name. Offering additional assistance at the end of the call to ensure all the callers' issues were handled appropriately thank the caller and provide appropriate branding at the end of the call..

[Audio] Before we wrap up do we have any questions or clarifications with our Quality guidelines? The detailed version of the Quality Guidelines is available in Care Connect. If you wish to read the full Centene Quality guidelines you may reach out our trainers team leaders and Quality team to direct you where to access it in Care Connect..

[Audio] Thank you for you time and we appreciate the partnership! Have a nice day!.