Mass General Brigham Health Plan · 2 days ago

Medicare Advantage Call Center/Enrollment Quality Reviewer

Somerville, MA

Full-time

Remote

Mid, Senior Level

5+ years exp

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Responsibilities

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

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

Partner with Medicare 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-specific metrics and reporting tools, ensuring these reflect evolving regulatory and business needs.

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

Participate in calibration sessions with Medicare 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 operations.

Qualification

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Quality MonitoringHealthcare ExperienceAuditingMedicare KnowledgeRegulatory ComplianceData AnalysisQuality Improvement MethodsQuality Monitoring SoftwareCall Center TechnologyReporting ToolsCoaching

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.