Medicare Advantage Quality Assurance Team Lead
Mass General Brigham Health Plan

Job Info

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This is a remote role that can be done in most US states.

The Quality Assurance Medicare Team Lead oversees the daily work assignments and quality assurance processes for the Medicare Advantage (MA) line of business, leveraging extensive expertise in Medicare operations, including Customer Service, Compliance, and Quality Assurance. This role collaborates closely with the Medicare Advantage Customer Service, Compliance, and Quality teams to ensure high standards of performance and quality in customer interactions, while providing ongoing support to Quality Control (QC) Reviewers in executing MA-specific tasks.

Key responsibilities include identifying and addressing performance issues by escalating concerns to the Manager, Quality Control, and assisting in the preparation and response to internal and external audits. The Medicare Team Lead also plays a vital role in refining QA processes by recommending updates to MA CS QA evaluation forms for Customer Service calls and generating detailed reports for QA management to drive improvements.

The Team Lead actively participates in operational meetings across departments-Medicare Advantage Customer Service, Compliance, and Quality Control-fostering collaboration, facilitating call calibration sessions, and ensuring alignment on quality standards. On a monthly basis, the Medicare Team Lead conducts an "audit the auditor" review to assess QC Reviewer performance and coordinates feedback and follow-up on challenges to MA CS scores, ensuring resolutions are made in partnership with the Manager, Quality Control.

Principal Duties and Responsibilities

• Provide daily direction and support for the QC Team specific to the Medicare Advantage (MA) line of business, ensuring clear communication and alignment with organizational goals.
• Collaborate with the Manager, Quality Control, to continuously monitor and update evaluation forms to ensure accuracy and relevance.
• Develop and maintain comprehensive MA job aids and desktop procedures tailored to the QA team's needs, ensuring they remain current and effective.
• Review QA Reviewer evaluations and audit challenges from Medicare Advantage Customer Service Professionals, following established processes to ensure fairness and accuracy.
• Conduct monthly audits of Explanation of Benefits (EOB) to ensure accuracy, compliance with Medicare guidelines, and high-quality customer communication.
• Deliver ongoing MA Customer Service (CS) updates and training to both new and experienced QA Reviewers, ensuring consistent knowledge and application of Medicare policies and procedures.
• Conduct live monthly coaching sessions for CS representatives to enhance skills, address challenges, and reinforce best practices in customer service.
• Work closely with MA CS leadership and Learning and Development, Claims, Grievances and Appeal, Enrollment and Compliance teams to identify and address gaps in training programs or Customer Service Guidelines (CSG), enhancing overall service delivery.
• Stay up to date on Medicare Advantage Customer Service changes, maintaining a high level of expertise through continuous training and monitoring of updates to ensure team alignment.
• Share responsibility for the team's performance, ensuring tasks are completed efficiently and that required metrics are consistently met or exceeded.
• Identify trends and skill gaps using data analysis and propose actionable improvements to enhance overall service delivery.
• Anticipate, meet, and exceed internal and external expectations, establishing and maintaining effective relationships across departments to ensure service excellence.
• Participate in or lead process improvement workgroups and special projects related to Medicare, driving efficiencies and innovation in service delivery and member experience.
• Hold yourself and team members accountable to meet commitments and quality standards.
• Ensure that diversity, equity, and inclusion are integral to all practices and decision-making processes within the team.
• Persist in achieving objectives, overcoming obstacles, and maintaining focus on results, regardless of challenges encountered.
• Build and foster strong relationships that reinforce the company's position as a people-first organization, centered on delivering quality care and service.
• Perform other duties as assigned, with or without accommodation, to support the organization's goals within the Medicare line of business.

Qualifications
Required:

• A high school diploma or GED is required, plus 4 years in a customer service environment.
• Extensive knowledge of Medicare Advantage a plus.
• Knowledge of customer service principles and practices.
• Knowledge on Microsoft Office (Teams, Excel, Outlook, etc.)
• Excellent verbal and written communication skills.
• Ability to work independently and part of a team.

Preferred/Desired:

• 2+ years of Medicare Advantage Customer Service experience is strongly preferred.
• Knowledge of call center telephony and technology is preferred.

About Us:

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world's leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.

Our work centers on creating an exceptional member experience-a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a consciously inclusive environment where diversity is celebrated.

We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more.

EEO Statement
Mass General Brigham is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. 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.

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