The Quality Assurance Specialist reports to the Director of Member Services or designee. The incumbent in this position is responsible for monitoring and rating member service representatives based on established quality guidelines. Uses collected data to provide training to promote and improve quality of service delivery.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Provide ad-hoc training and guidance to member services and provider services representatives based on the results of quality audits.
• Conduct formal training sessions in both a face-to-face and virtual training environment.
• Conduct call quality audits on member services and provider services calls.
• Conduct auditing of call center documentation.
• Participate in regular QA calibration sessions with call center representatives and management.
• Report trends to leadership identified through the completion of call quality audits.
• Assess additional training needs and identify and report opportunities for additional training resources and resources to leadership.
• Design, develop, and implement new training within the department.
• Assist with the coordination and facilitation of new-hire and continuous training.
• Design and develop new quick reference guides and just-in-time communications to staff.
• Serve as a subject-matter expert for direct reports in the areas of Part C, Part D, Medicare Parts A & B, Medicare claims billing, and payments.
• Collaborate with leadership to identify coaching and training opportunities.
• Communicate time-sensitive information to staff through a variety of mediums, such as SharePoint, acknowledgment management system, e-mail, and huddles.
• Assist staff with resolving escalated member and provider calls.
• Assess department adherence to all federal, state, and organizational regulations and policies and procedures pertinent Medicare Advantage call center operations.
• Assist with the designing, development, and implementation of quality assurance initiatives.
• Collaborate with subject matter experts within the organization to address escalated member/provider inquiries and issues.
• Participates in training and in-service education as required.
• Participates in department, clinic and other meetings as requested.
• Complies with the organization's policies and procedures and maintains confidentiality in accordance with state and federal laws.
• Participates in special projects and performs other duties as assigned.