Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents.
We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
The Customer Solution Center Quality Auditor (QA) II is responsible for monitoring and actively influencing the Customer Solution Call Center team's quality performance, ensuring that the quality requirements in place are fulfilled and the goals are consistently achieved. This position will analyze quality results and performance in order to identify and optimize processes and support staff development, in partnership with the Quality Assurance Management.
This position will identify processes, situations, and opportunities where improvement is needed and be responsible for creating performance reports and action plans. The position will maintain a high level of based knowledge on benefits for all product lines (Medi-Cal, CMC, PASC, Healthy Kids and Covered California) as well as serve and act as the department's SME (Subject Matter Expert). This position will assist in the development of tools and procedures established to audit each vertical under the Customer Solution Center. In addition, this position will make recommendations for individual and group training/retraining and process improvements.
This position will assist in the development of training materials delivered to various internal departments and off site Call Center vendor to measure product knowledge. As needed, this position will be assisting and conducting training for new onboarding QA staff and assist and support trainers with academy classes.
Conduct audits to ensure that regulatory and quality requirements were met across all verticals under CSC. Conducts random member audits and surveys to ensure the member experience has a positive outcome. Responsible for monitoring call center, including Call Center Leads, Outbound and Outreach, Ansafone, Web Inquiries, M.R.U. (Member Relations Unit), and Appeals and Grievance, performance against key performance indicators and recognizes trends that require individual or group retraining. Conducts/reviews audits and analyzes the data and documentation and provides their input to management for review. Tracks and trends daily error reports, analyze results from Call Center, MRP, Medicare, M.R.U., Outbound and Outreach, and L.A. Care Covered scorecards and recommend quality improvements for the CSC Department. Create and assist in developing Desk Level Procedures (DLP) for all supporting units. (65%)
Performs and assist with weekly calibrations. Assists with new hire training (CSC and QA) and/or up training, assess class curriculum, Desk Level Procedures (DPL), and recommend changes as necessary. Compiles quality data on a daily/monthly basis to measure compliance with internal policies and procedures as well as regulatory requirements. Reviews quality reports, outcomes, recommends corrective action plans as needed and reports irregularities or vulnerabilities to appropriate parties as deemed necessary. Frequently compiles quality data to measure compliance as well as regulatory requirements. Review quality reports, outcomes, recommend corrective action plans as needed and report irregularities or vulnerabilities to appropriate parties as deemed necessary. (15%)
Provides 1:1 Coaching Assessments to all pertinent departments. Consistently participates in quality initiatives and special project task forces as deemed necessary. Works with unit managers to develop quality tools to monitor potential departmental vulnerabilities (Membership Accounting, Call Center Unit, Outbound and Outreach, and Member Relations Unit). Provides unit managers and departmental director with analysis on the error trends and provide recommendations for improvements. Serves as the subject matter expert for all Lines of Business (Medi-Cal, CMC, PASC/SEIU, Healthy Kids, L.A. Care Covered...); in addition to programs used at L.A. Care: MHC, MEIS, QNXT, QMEIS, IVR, NICE, MEDACCESS, TTY, SALESFORECE, MEDIASENSE, CISCO FINESSE, WEX CALLBACK and RETRO Process, AEVS, IHSS Website, and Provider Search Oracle. Reviews targeted audit text documentation (MIU, CC, MRP and Member Relations) and update quality screens via NICE/Access/MHC/MEIS/QMEIS software. The QA is also responsible for assisting Call Center with call intake as needed. (10%)
Performs other duties as assigned. (10%)
High School Diploma/or High School Equivalency Certificate
At least 0-2 years of quality assurance experience preferably in healthcare's Member Services or Quality Assurance.
Knowledge of and experience of Medi-Cal, Medicare, and Covered California.
Working knowledge of a CRM, AEVS, and other benefit eligibility programs.
Good oral and written communication skills.
Strong analytical skills, excellent technical skills and attention to detail.
Excellent technical skill.
Strong research skills.
Intermediate knowledge of MS Office.
Ability to coach and train employees.
American Society for Quality - Certified Quality Auditor (ASQ - CQA) Certification
L.A. Care offers a wide range of benefits including
Paid Time Off (PTO)
Medical, Dental and Vision
Volunteer Time Off (VTO)
Nearest Major Market: Los Angeles
Job Segment: Audit, Medical, Medicare, Call Center, Finance, Healthcare, Customer Service
L.A. Care Health Plan