Jobs in Vaughan, United States

The Quality Control Reviewer for Medicare Advantage and DSNP is a vital member of the quality assurance team, focused on monitoring and evaluating Medicare Advantage and DSNP customer service calls, transactions, and member enrollment processes. This position ensures compliance with quality standards, regulatory requirements, and service excellence within the Medicare Advantage and DSNP line of business. Collaborating closely with the Medicare Advantage and DSNP Quality Assurance Team Lead and relevant departments, this role identifies areas for improvement, provides feedback, and helps develop best practices to enhance both customer service interactions and enrollment processes.

The Quality Assurance Reviewer is responsible for identifying potential areas of concern or compliance risk and partnering with the Quality Assurance Team Lead on appropriate follow-up. Follow up may include feedback, coaching or collaboration with other departments to improve documentation or business process. This person must have the ability to apply an end-to-end process orientation to their work. The Quality Control Reviewer may also participate in targeted quality control projects for key accounts to ensure transactional integrity.

The Quality Assurance Reviewer is a key member of a dynamic team, reporting to the Manager, Quality Control. This position contributes to the monitoring of key business processes and may participate in agile projects as the need arises.

Principal Duties and Responsibilities:

• Conduct comprehensive reviews of Medicare Advantage and DSNP customer service calls, enrollment interactions, and transactions to assess accuracy, compliance, member experience, and service quality.

• Apply Medicare Advantage and DSNP-specific guidelines, job aids, and regulatory standards to ensure interactions are compliant, high-quality, and member-centered.

• Partner with Medicare Advantage and DSNP customer service and enrollment teams to identify process improvements, address quality gaps, and implement enhancements.

• Document audit findings, assign scores, and generate detailed reports for QA management, highlighting patterns, insights, and actionable improvements.

• Assist in developing Medicare Advantage and DSNP specific metrics and reporting tools, ensuring these reflect evolving regulatory and business needs.

• Support onboarding and training of Medicare Advantage and DSNP customer service and enrollment staff by sharing key quality insights and performance feedback.

• Participate in calibration sessions with Medicare Advantage and DSNP Customer Service, Compliance, and Quality Control teams to standardize scoring practices and align quality standards.

• Engage with customer service representatives and enrollment staff to resolve audit challenges, clarify guidelines, and enhance service delivery standards.

• Contribute to quality improvement projects, including agile initiatives focused on Medicare Advantage and DSNP operations.

Required:

• Associate degree or an equivalent combination of education and experience in healthcare, customer service, or auditing.

• At least 5 years of experience in healthcare, with 3 years in quality monitoring, auditing, or similar roles.

• Experience in evaluating customer service calls, especially within healthcare or insurance sectors, with a focus on regulatory and compliance standards.

Preferred/Desired:

• Bachelor's degree in healthcare administration, business, or a related field.

• Direct experience in Medicare Advantage and DSNP customer service, including familiarity with Medicare Advantage and DSNP enrollment processes and specific regulatory requirements.

• Experience working with quality monitoring software (e.g., CX1 or similar platforms) and call center technology.

• Familiarity with healthcare quality improvement methods and data analysis skills for reporting on quality metrics.

Skills:

• Critical Listening Skills: Ability to actively listen and analyze call interactions to evaluate service quality, adherence to Medicare Advantage and DSNP guidelines, and member engagement.

• Medicare Advantage and DSNP Specific Knowledge: In-depth understanding of regulations, claims processing, and enrollment procedures, ensuring accurate and compliant evaluations.

• Technical Proficiency: Familiarity with quality monitoring systems (e.g., CX1) and call center technology, with the capability to leverage these tools for efficient evaluations.

• Communication Skills: Strong ability to clearly articulate feedback and recommendations, both in written reports and during team discussions, tailored for various audiences.

Working Conditions

• This role is a full-time, daytime role with a Monday through Friday schedule. Typical hours are between 9:00 AM and 5:00 PM EDT
• It is a remote role that can done from most US states

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.