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Site: Mass General Brigham Incorporated<p style="text-align:inherit"><br> </p><p style="text-align:left">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.</p><p style="text-align:inherit"><br> </p><p style="text-align:inherit"><br> </p><p style="text-align:left"><u><b>Job Summary</b></u></p>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.<p style="text-align:inherit"><br> </p><div><div><div><div><div><div><div><p style="text-align:left"><u><b>Qualifications</b></u></p></div></div></div></div></div></div></div><p>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. </p><p>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.</p><p></p><p><b>Principal Duties and Responsibilities:</b></p><ul><li><p>Conduct comprehensive reviews of Medicare Advantage and DSNP customer service calls, enrollment interactions, and transactions to assess accuracy, compliance, member experience, and service quality.</p></li><li><p>Apply Medicare Advantage and DSNP-specific guidelines, job aids, and regulatory standards to ensure interactions are compliant, high-quality, and member-centered.</p></li><li><p>Partner with Medicare Advantage and DSNP customer service and enrollment teams to identify process improvements, address quality gaps, and implement enhancements.</p></li><li><p>Document audit findings, assign scores, and generate detailed reports for QA management, highlighting patterns, insights, and actionable improvements.</p></li><li><p>Assist in developing Medicare Advantage and DSNP specific metrics and reporting tools, ensuring these reflect evolving regulatory and business needs.</p></li><li><p>Support onboarding and training of Medicare Advantage and DSNP customer service and enrollment staff by sharing key quality insights and performance feedback.</p></li><li><p>Participate in calibration sessions with Medicare Advantage and DSNP Customer Service, Compliance, and Quality Control teams to standardize scoring practices and align quality standards.</p></li><li><p>Engage with customer service representatives and enrollment staff to resolve audit challenges, clarify guidelines, and enhance service delivery standards.</p></li><li><p>Contribute to quality improvement projects, including agile initiatives focused on Medicare Advantage and DSNP operations.</p></li></ul><p></p><p style="text-align:inherit"><br> </p><div><div><div><div><div><div><div><p style="text-align:left"><u><b>Additional Job Details (if applicable)</b></u></p></div></div></div></div></div></div></div><p><b>Required:</b></p><ul><li><p>Associate degree or an equivalent combination of education and experience in healthcare, customer service, or auditing.</p></li><li><p>At least 5 years of experience in healthcare, with 3 years in quality monitoring, auditing, or similar roles.</p></li><li><p>Experience in evaluating customer service calls, especially within healthcare or insurance sectors, with a focus on regulatory and compliance standards.</p></li></ul><p></p><p><b>Preferred/Desired:</b></p><ul><li><p>Bachelor’s degree in healthcare administration, business, or a related field.</p></li><li><p>Direct experience in Medicare Advantage and DSNP customer service, including familiarity with Medicare Advantage and DSNP enrollment processes and specific regulatory requirements.</p></li><li><p>Experience working with quality monitoring software (e.g., CX1 or similar platforms) and call center technology.</p></li><li><p>Familiarity with healthcare quality improvement methods and data analysis skills for reporting on quality metrics.</p></li></ul><p></p><p><b>Skills:</b></p><ul><li><p>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.</p></li><li><p>Medicare Advantage and DSNP Specific Knowledge: In-depth understanding of regulations, claims processing, and enrollment procedures, ensuring accurate and compliant evaluations.</p></li><li><p>Technical Proficiency: Familiarity with quality monitoring systems (e.g., CX1) and call center technology, with the capability to leverage these tools for efficient evaluations.</p></li><li><p>Communication Skills: Strong ability to clearly articulate feedback and recommendations, both in written reports and during team discussions, tailored for various audiences.</p></li></ul><p></p><p><b>Working Conditions</b></p><ul><li>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</li><li>It is a remote role that can done from most US states</li></ul><p style="text-align:inherit"><br> </p><div><div><div><div><div><div><div><p style="text-align:left"><u><b>Remote Type</b></u></p></div></div></div></div></div></div></div>Remote<p style="text-align:inherit"><br> </p><div><div><div><div><div><div><div><p style="text-align:left"><u><b>Work Location</b></u></p></div></div></div></div></div></div></div>399 Revolution Drive<p style="text-align:inherit"><br> </p><div><div><div><div><div><div><div><p style="text-align:left"><u><b>Scheduled Weekly Hours</b></u></p></div></div></div></div></div></div></div>40<p style="text-align:inherit"><br> </p><div><div><div><div><div><div><div><p style="text-align:left"><u><b>Employee Type</b></u></p></div></div></div></div></div></div></div>Regular<p style="text-align:inherit"><br> </p><div><div><div><div><div><div><div><p style="text-align:left"><u><b>Work Shift</b></u></p></div></div></div></div></div></div></div>Day (United States of America)<p><br><br> </p><p><u><b>Pay Range</b></u></p>$25.00 - $35.77/Hourly<p><br> </p><p><u><b>Grade</b></u></p>5<p><br> </p>At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.<p><br> </p><div><div><div><div><div><div><div><p style="text-align:left"><u><b>EEO Statement:</b></u></p></div></div></div></div></div></div></div>Mass General Brigham Incorporated is an Equal Opportunity Employer. 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. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.<p style="text-align:inherit"><br> </p><h2><u><b>Mass General Brigham Competency Framework</b></u></h2><div><div><p style="text-align:left">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.</p></div></div>
