Step Up Your QA Career ! Senior Quality Evaluator/Analyst

Concentrix Philippines; Philippines; On-site; PHP 300,000 - 600,000; Full time

Job summary

Concentrix Philippines is seeking a quality auditor to monitor and evaluate inbound and outbound calls, chats, and emails, ensuring scoring consistency and adherence to best practices. You will participate in calibration sessions and support audits to improve overall contact quality.

You will provide actionable feedback to nursing and appeals teams, ensure CMS Part C regulatory compliance, and maintain strict confidentiality of member information while documenting resolutions and preparing

Qualifications

• Medical allied graduate with active and valid license.
• Minimum 1 year appeals/grievances experience in Medicare Part C.
• At least 1 year QA in contact center.
• Knowledge of CMS Part C regulatory standards.
• Strong clinical terminology and healthcare insurance knowledge.
• Experience supporting external audits.
• Mentoring new quality staff.
• Attention to detail and documentation skills.

Responsibilities

• Monitor, evaluate, and audit calls and other contact methods.
• Participate in calibration and call listening with stakeholders.
• Contribute to internal quality audits to improve contact quality.
• Meet audit requirements and report results to stakeholders.
• Adhere to CMS guidelines and maintain confidentiality of sensitive member information.
• Document interactions and resolutions in the system.
• Prepare reports to support compliance and auditing.
• Provide feedback to improve processes and regulatory compliance.
• Collaborate with training to identify learning gaps and upskilling initiatives.

Skills

Quality assurance

CMS Knowledge

Healthcare terminology

Auditing

Documentation

Analytical thinking

Education

Licensed medical professional

Tools

MS Office

Quality audit systems

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