Be Part of Our Team ! Senior Quality Evaluator/Analyst

Concentrix Philippines; Quezon City; On-site; PHP 350,000 - 600,000; Full time

Job summary

Concentrix Philippines is seeking a qualified quality auditor for Medicare-related appeals in a contact center environment in Quezon City. You will monitor, evaluate, and document interactions, ensuring compliance with CMS Part C standards.

The ideal candidate is a medical allied graduate with an active license, has at least 1 year in appeals/grievances, and can provide structured feedback and reports to support performance improvements and regulatory compliance.

Qualifications

• Medical allied graduate with active license (e.g., PHRN, Pharmacist, Psychometrician).
• Minimum 1 year in appeals/grievances workstreams focusing on Medicare Part C appeals.
• Minimum 1 year in a contact center QA/quality evaluator role.

Responsibilities

• Monitor, evaluate, and audit a sampling of inbound/outbound calls and other contact methods (chats, emails).
• Participate in calibration and call listening sessions to ensure scoring consistency and best practices.
• Participate in internal quality audits to improve contact quality and recommend changes.

Skills

Quality auditing

Call evaluation

Calibration

Documentation

Microsoft Office

Education

Medical allied degree with license

Tools

Microsoft Office Suite

Job description

About the role

This role involves monitoring, evaluating, and auditing inbound and outbound calls and other contact methods including chats and emails. You will participate in calibration and call listening sessions with quality staff, delivery, and clients to ensure scoring consistency and best practices, and participate in internal quality audits designed to improve overall contact quality.

Key responsibilities

• Monitor, evaluate, and audit a sampling of inbound or outbound calls and other contact methods including chats and emails

• Participate in calibration and call listening sessions with quality staff, delivery, and clients to ensure scoring consistency and best practices

• Participate in internal quality audits designed to improve overall contact quality and recommend changes

• Meet audit requirements and report results of evaluations to stakeholders

• Adhere to all CMS guidelines and company policies and maintain confidentiality of sensitive member information

• Accurately document all interactions and resolutions in the system

• Prepare reports as required to support compliance and auditing requirements

• Provide insights and feedback on recurring issues to improve processes

• Provide structured feedback to appeals nurses, case coordinators, and appeals representatives to support performance improvement and regulatory compliance

• Collaborate with training and operations to identify learning gaps and provide input on ongoing upskilling initiatives

About you

• Medical allied graduate with active and valid license (e.g., PHRN, Registered Pharmacist, Psychometrician)

• Minimum 1 year experience in appeals and grievances workstreams with focus on Medicare Part C appeals

• Minimum 1 year experience in a similar role or function in a contact center setting (quality assurance or quality evaluator)

• In-depth knowledge and understanding of CMS Medicare Part C appeals regulatory standards

• Strong understanding of clinical terminology, medical necessity review principles, and healthcare insurance operations

• Experience supporting external audits (CMS program audits and client audits)

• Experience mentoring or coaching new quality staff

• High attention to detail with strong documentation, writing, and scoring calibration skills

• Proficiency in quality audit systems and Microsoft Office Suite

• Strong analytical, critical thinking, and problem solving skills