Medicare Advantage Call CenterEnrollment Quality Reviewer
Medicare Advantage Call CenterEnrollment Quality Reviewer
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Job Description
Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a not-for-profit we support patient care research teaching and community service striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
Job Summary
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.Qualifications
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.
Additional Job Details (if applicable)
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:
Bachelors 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
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$25.00 - $35.77/HourlyGrade
5EEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance make hiring decisions identify development needs mobilize employees across our system and establish a strong talent pipeline.
Employment Type
Full-Time
