Med-D New Hire QA Talk

[Audio] Hello My Name is Bobby and welcome to the Quality Form Discussion for Med-D using the WeCare Form 2025. In this session, we will walk you through how our Quality Assurance Associates evaluate your calls. The goal is to give you a clear understanding of the scoring process—what specific behaviors and actions are being measured, what practices you should continue doing to deliver excellent service, and which behaviors to avoid that may negatively impact your score..

[Audio] By the end of this discussion, you will have a stronger understanding of how your performance is evaluated and how the feedback ties into our overall quality standards. This session will also serve as a practical guide to help you improve continuously and ensure every customer receives a consistent, world-class experience. In this training, we will: Understand the components of the WeCare Form – what they are and why they matter. Learn the importance of each component and how they are scored – so you know exactly how your performance is measured. Gain awareness of the most common markdowns – and learn how to avoid them to maintain high-quality interactions..

[Audio] Introducing the Med-D We care Form The current WeCare form is designed not only to measure skills and behaviors related to call quality but also to directly influence Overall Member Satisfaction, measured through OSAT and NPS. By focusing on both technical accuracy and customer experience, the form ensures that every interaction contributes to building trust, delivering value, and maintaining consistency. Our Quality Goal = 90% This benchmark reflects our commitment to excellence and serves as a standard for every interaction handled..

[Audio] Let's move on to Greeting, which is worth 3 points in our quality form. The greeting is the very first impression the caller has of us. Think of it as the moment we open the door — the way we welcome someone sets the tone for the entire conversation. Here are the key expectations: Answer the call within 3 seconds. Anything longer can already create frustration for the caller, especially if they're reaching out with an urgent need. Provide an appropriate or customized greeting. A simple standard greeting could be: "Thank you for calling, my name is [Name]. How can I help you?" When possible, encourage adding a touch of personalization. For example: "Thank you for calling, this is [Name]. I'll be happy to assist you today." This small adjustment helps callers feel acknowledged and welcomed. Thank the member for calling. A sincere "thank you" shows appreciation and starts the interaction on a positive note. Introduce yourself by name. This builds trust and accountability, as the caller knows exactly who is assisting them. When we consistently follow these steps — answering quickly, greeting warmly, and identifying ourselves clearly — we don't just meet expectations. We create a welcoming, professional experience that makes the caller feel respected and cared for from the very start..

[Audio] Next, let's talk about Authentication, which carries the highest weight at 11 points. Authentication is critical because it protects member privacy, reduces the risk of any privacy breach, and most importantly, allows members to feel safe and supported when speaking with us. Here are the key expectations: For non-CTI authenticated callers, we need to obtain their first and last name, date of birth, zip code or plan sponsor, and Member ID, MBI, or Rx number. These details are required to properly validate the caller. If the caller is already authenticated through CTI or IVR, we must still verify who we are speaking with and take the appropriate action depending on their role. For third-party callers, make sure to obtain and document their first and last name, then confirm with the key question: 'Is the member aware you are calling today?' This protects against unauthorized disclosures. For pharmacies and medical doctors, ensure you obtain the NCPDP, NPI, or NABP number as required. During internal or external transfers, always follow the proper authentication process and confirm the caller's identity is still validated. Lastly, for SRT or cold transfers, if a member refuses authentication, we must check if the Senior Rep or Care Coordinator followed the proper authentication process before proceeding. The bottom line here is that authentication is not just a compliance step—it's about protecting sensitive information and building trust. Any missed step here could compromise both member privacy and our integrity as their trusted partner..

[Audio] For this section, let's focus on Verifying Member Information and Account Wellness, which is worth 3 points. This step ensures that the member's account is accurate, complete, and up to date. It may seem routine, but it's a key part of delivering quality service and avoiding future issues. Here's what we need to keep in mind: Always verify and update member details as needed, following the Work Instructions. Confirm the address, phone number and type—whether it's mobile or landline—and email address. Having the right contact details ensures smooth communication. Conduct an Account Wellness review to check for gaps or updates that might benefit the member. Update messaging preferences if the member wants changes in how they receive communications. Now, when speaking with a third-party caller—like a spouse or family member—review the account but do not make unauthorized changes. If you find an issue, advise the caller that the member must contact Customer Care directly. This protects the member's privacy while still being helpful to the caller. The main takeaway here is: keeping member information accurate not only prevents service interruptions but also helps us show care by ensuring their account is fully aligned with their current needs..

[Audio] Now, let's move into Determining the Reason for the Call, which carries 8 points—so it's one of the heaviest weighted areas in our evaluation. This step is about making sure we fully understand why the member is calling, what their immediate concern is, and how we can best resolve it. Here's how we do that effectively: Start with clear opening questions, such as: 'Are you calling about a medication today?' or 'What can I help you with today?' This sets the tone and quickly identifies the main purpose of the call. If the call is about medications, always ask the day supply the member has on hand. This helps us measure urgency and plan next steps. Practice active listening—don't just hear the words, but understand the concern. Use open-ended and probing questions to uncover the root cause, not just the surface issue. Show understanding by paraphrasing or restating the member's need. For example: 'So just to confirm, you're concerned about…' Apply SRT (Service Resolution Tactics): determine the urgency of the call and whether it can be resolved right away or needs escalation. The key here is: when we properly identify the reason for the call, we set ourselves up for the right solution the first time—reducing repeat calls, increasing satisfaction, and building trust with our members.".

[Audio] Next, let's talk about Compliance, which carries the highest weight of 11 points. This is not just about quality—it's about protecting our members, the company, and ourselves. Compliance ensures that every interaction is secure, ethical, and aligned with CMS guidance. Here's what that means in practice: Always check the Privacy Health Record—look for the padlock icon—and review the privacy screen before assisting. Protect all PHI, PII, and HIPAA-sensitive information at all times. A single slip here can mean serious consequences. Follow the correct processes for Coverage Determination, Redetermination, and Appeals. When filing a GRV, do so exactly as required by Work Instructions or CIF, and make sure you file the correct type. If you encounter fraud, waste, or abuse, it must be reported immediately—there is zero tolerance for overlooking these incidents. For clinical inquiries, follow protocol and transfer to Clinical Care as required. Documentation and scripting aren't optional—they are mandatory compliance requirements. Lastly, for SRT, confirm if a GRV has been filed for Medicaid when applicable. This section is critical because it protects our members' privacy and ensures that Alorica remains compliant with Medicare and CMS guidelines. Every misstep in compliance puts both the member and the business at risk, which is why it carries the highest point value in our quality framework..

[Audio] Now let's move on to Verbal Presentation, which is worth 4 points. This section is about how we speak to members and the overall impression we leave behind. The goal here is to BE HUMAN—to create a positive and memorable experience for the member. That means verbally demonstrating a genuine willingness to help, tailoring the conversation to the member's needs, and using language that is clear, polite, and encouraging. Here's what that looks like: Use positive words and affirmations—simple phrases like 'Absolutely,' 'I'll be happy to help,' or 'Thank you for waiting' go a long way. Explain processes in an easy-to-understand manner, avoiding technical jargon. Members don't need system terms; they need clarity. Keep your communication clear, concise, and straightforward, especially when explaining complex details. Use basic etiquette—words like 'please' and 'thank you'—because courtesy always counts. Avoid negative connotations, personal opinions, or unnecessary comments about internal or external partners. Address members by their first name whenever appropriate, unless they request otherwise—it helps personalize the interaction. For SRT, remember: Instead of just saying 'no', focus on what you can do, and avoid repeating the same answer over and over. Verbal Presentation is about creating an experience where the member not only receives the information they need but also feels valued, respected, and supported throughout the call.

[Audio] After focusing on what we say with Verbal Presentation, let's shift to how we say it—because tone, empathy, and sincerity can completely change how members experience the call This section is called Caller Impact, and it carries 7 points. Here, we really emphasize the human side of the interaction. It's all about making members feel cared for and supported. That means: Using an enthusiastic and welcoming tone—your energy should come through in your voice. Letting the caller 'hear the smile'—because warmth is noticeable even over the phone. Treating every member like a person, not a transaction. Showing empathy by acknowledging concerns and connecting with what they're saying. Instilling confidence—members need to feel that you're their advocate and that they can trust you. Staying respectful and professional throughout, even if the caller is upset. Matching the caller's pace so they don't feel rushed, and pausing to let them speak without interruptions. Remember: Caller Impact is about building trust, not just solving the problem. When members feel heard, valued, and respected, the interaction becomes more than a call—it becomes a positive experience..

[Audio] Now that we've covered how tone and empathy impact the call, let's move on to another critical area—Accuracy. Because even the most friendly interaction loses its value if the information we give isn't correct." This section focuses on Accuracy, which is worth 11 points. Accuracy is the foundation of trust. Members depend on us not just to sound confident, but to actually provide reliable, precise, and up-to-date information. Every detail matters, because one incorrect piece of information can affect their decisions, coverage, and even their satisfaction. To achieve this, we focus on key expectations: Always provide information directly from the Work Instruction or Client Information Form (CIF). Ensure costs, coverage, and premium quotes match what's outlined in the system. Select the correct account or line of eligibility so there's no confusion. Give the right turn-around time or order information—accuracy here prevents delays and frustration. Provide the correct plan design and client information details. Share accurate Prior Authorization (PA) information. And finally, for SRT calls: do not rely only on comments or CCR narratives. Always go back to the source material. When we're accurate, we not only resolve the member's concern—we also strengthen their confidence in us as a trusted partner..

[Audio] Now that we've emphasized the importance of providing accurate information, the next step is about accountability—how we take full responsibility for the member's experience. This brings us to Call Ownership. Call Ownership is worth 7 points, and it's about making sure members feel that we own their issue from start to finish. Members don't want to be passed around, told to call back, or left uncertain about the next step. They want to feel that the person they reached is the person who will make sure their concern gets resolved. To do this, here are the expectations: Take responsibility for resolving the issue, using 'yes I can' statements to reassure members. Set realistic expectations and clearly communicate them. Let members know your purpose is to remove barriers so they can get what they need, like their medication. Create a hassle-free experience by minimizing unnecessary steps. Take ownership of repeat or transferred calls—don't push responsibility back to the member. Avoid unnecessary transfers, and don't escalate without researching first. Prevent members from doing the legwork or extra "homework." Step in when appropriate to eliminate pushback and maintain control of the call. Show urgency in addressing the concern. And for SRT: remain engaged, even in complex calls or when seeking support. When we take ownership, members feel secure knowing that someone is fully committed to resolving their concerns..

[Audio] After establishing call ownership, the next focus is on how we actually manage the flow of the conversation. This is where Call Handling comes in. Call Handling is worth 5 points, and it's all about moving through the call effectively and efficiently without losing connection with the member. Here's what that looks like: Keep a flexible cadence so the call doesn't feel rushed or dragged out. Maintain control of the call to keep the conversation on track. Avoid unnecessary holds or long silences—members should always feel engaged. If a hold is needed, notify the member first, and always thank them afterward. Transfers should always be done correctly—whether it's to a client team, internal department, or external department. And whenever possible, perform a warm transfer rather than a blind one. Follow the proper disconnect process per work instructions. And lastly, demonstrate efficient system navigation so the member feels the call is smooth and professional. In short, effective call handling ensures members feel like their time is valued and that we're in control of guiding the interaction from start to finish..

[Audio] Another critical driver of success is making the most out of the resources we already have. Tools and systems are there not just to assist us, but to empower us to provide faster, more accurate resolutions. This section is worth 8 points, and it's about making sure we leverage every program, system, and resource to resolve the caller's inquiry quickly and accurately. Here's what that means in practice: Always access the correct work instructions and client information forms to guide the call. Use the right systems like TEAMS Chat, AS400, Compass, MARx, or PeopleSafe to find accurate answers. Follow every step outlined in the CIF and WI — skipping steps can mean giving incomplete or inaccurate information. Use available tools to process requests like FastStart, New Rx, Test Claims, and Prior Authorization forms. And for SRT, ensure tools are used effectively so you resolve issues without delays. The bottom line: By fully using the tools at our disposal, we not only resolve issues more efficiently, but we also create a seamless experience for the member, showing them that we are knowledgeable, resourceful, and fully equipped to help..

[Audio] Now let's move on to how we can increase a member's knowledge of their plan design. It's very important that we provide accurate, complete, and clear information so members fully understand their benefits and costs. Here's what we need to make sure we cover, as applicable to the work instruction: Provide Plan Design details (TROOP, Coverage Gap, Catastrophic, Cost of Plan, etc.) → so the member understands how their benefits change throughout the year. Provide a drug copay disclaimer → to set clear expectations and avoid billing surprises. Share drug coverage information → so members know if their medication is included. Confirm if the member is using an in-network pharmacy → because this impacts cost and accessibility. Provide details about the deductible → to explain what the member must pay before coverage begins. Address any premium billing inquiries and dunning → to prevent confusion and ensure timely payments. Provide information about the formulary and alternatives → so members know their options if a drug isn't covered. By ensuring all of these details are shared, we not only resolve the member's concern but also build trust and help them feel confident navigating their plan. This line item is worth 4 points in our audit form..

[Audio] After focusing on plan design, let's take it a step further and talk about self-service education options for 3 points. These tools not only help members resolve issues faster but also empower them to take more control of their healthcare journey. This part is all about explaining resources that are readily available for members. Instead of just solving the issue during the call, we can guide them toward tools that will make their future interactions easier and more efficient. For example, we can: Walk them through the website or mobile app features. Enroll them in the Caremark Messaging Platform for timely reminders and updates. Highlight options like auto refill or auto renew, so they never miss a prescription. Share financial assistance programs that could reduce costs. And whenever available, follow the Health Engagement Engine to tailor education. The expectation here is not to overwhelm the member with everything at once, but to choose what's relevant to their need and call type. Even one well-placed education point can make a big difference in their experience.".

[Audio] Now that we've covered education and self-service options, let's move to one of the most important aspects of the call — resolution which weighs 10 points. This is where everything we've discussed so far comes together, because at the end of the day, what matters most to our members is getting their concern fully resolved. Resolution is at the heart of delivering excellent service. It's not just about answering the question — it's about making sure the member feels confident that their concern has been handled. Here's what's expected from us: Identify and address all concerns — don't leave any loose ends. Provide timely solutions especially for urgent or critical needs. Take committed actions so the member knows exactly what's being done. Ensure everything has been addressed before wrapping up. And finally, always summarize or recap the call. Restating the reason for the call, the action you took, and the next steps leaves the member reassured and confident. If we can consistently deliver on these, we achieve First Call Resolution, which is not only a key metric but also a major driver of member satisfaction..

[Audio] We've talked about resolving the member's concerns, but resolution isn't truly complete without a strong and professional closing. This is the last impression we leave with the caller, and it plays a big role in how they feel about the overall experience." Closing the call may seem like a small step, but it's actually very powerful. Here's what's expected of us: First, always offer additional assistance. Ask if there are any other concerns or needs that may be addressed before ending the call. This shows attentiveness and prevents callbacks. Second, use the SRT process to confirm that the resolution is acceptable for the member or caller. This is also the point to complete an account review when appropriate, ensuring nothing has been missed. Third, never forget to thank the caller for calling. A simple thank you goes a long way in leaving a positive final impression. And lastly, close the call with an appropriate closing. Whether it's a polite 'Have a great day' or 'We appreciate your time,' the goal is to leave the caller reassured and valued. By consistently following these steps, we reinforce professionalism and ensure that members walk away from every interaction feeling fully supported. This Line item is worth 3 points..

[Audio] Now that we've guided the member through their concern and closed the call professionally, the last but equally critical step is documentation which is 2 points equivalent in our evaluation form. Accurate documentation protects both the member and us as representatives, ensuring consistency and accountability. This also helps the next CSR understand the history of the calls for a particular account. When documenting the account, our goal is to be thorough, accurate, and concise. Here's what that looks like in practice: First, always use the appropriate log activity codes and select the correct reason for call in COMPASS. This ensures proper categorization and reporting. Second, make sure to use the correct disposition or form of contact when capturing activity. This avoids errors and confusion later on. For Health Plans, it's important to document using the FCR GRV template and Log Activity code 1319 in PeopleSafe. This standard keeps our process aligned with client requirements. Beyond that, always reference any systems used in resolving the member's concern. For example, when Salesforce or other tools are involved, include the reference number so the documentation can be easily tracked. And finally, leverage SRT to make sure all necessary details are included and the documentation is tied back to the resolution provided. By following these steps, we leave a complete, accurate record of the call that supports both compliance and quality performance..

[Audio] Thank you again for attending our Quality Talk. I truly appreciate the time and attention you gave today. I hope you've learned a lot from this session and that the examples and guidelines we shared will help you in your day-to-day work. Please remember that you can always go back to the material and ask your facilitator if you need any clarifications or more samples. At the end of this course, a CFU—or check for understanding quiz—will be sent out for you to complete. Most importantly, I want to wish you success on the floor. The skills and knowledge you've gained here will not only help you perform better but also build your confidence in handling calls. If you're ready, let's proceed with the CFU. Good luck, and I look forward to seeing your success!.