Member Services Quality Auditor

POSITION SUMMARY

Screens incoming and outgoing calls to ensure quality, customer service, and adherence to the policies and procedures of the department. Provides feedback to Director of Member Services and Supervisor(s) to assist in the creation of performance improvement goals and the development of training programs and

COMPLIANCE WITH REGULATIONS:

Ensures the Member Service Department is following the DHCS and CMS regulations related to potential misclassified inquiries.

RESPONSIBILITIES

• In depth, understanding of all of the DHCS and CMS regulations related to potential misclassified inquiries that could lead to grievances.

• Keeps up on all relevant changes to the DHCS and CMS regulations.

• Identifies areas of improvement for existing auditing and monitoring quality improvement processes.

• Performs daily audits on Inquiries (Risk Based, sampling w/95% confidence level).

• Monthly audits on member calls scoring for the 33 Points of MAGIC.

• Monthly audits of Welcome Calls ensuring 100% completion, including the timely completion (CMC calls all happen prior to month and Medi-Cal Welcome calls happen during the first two weeks of the month).

• Monthly audits of cases ensuring case documentation accuracy.

• Daily TTY Testing to ensure compliance with CMS regulations.

• Inputs audit data into report repositories for Employee Monthly Scorecards and Executive Dashboard Reporting.

Qualifications

EDUCATION

• Bachelor's Degree Preferred

• Mastery of the 33 Points of MAGIC (Customer Service Program)

EXPERIENCE/ SKILLS

• Three years of experience in Customer Service (preferably in the health care industry).

• Strong customer service background.

• Familiarity with case documentation practices.

• Strong analytical skills

• Superior attention to detail

• Experience with and sensitivity to cultural background and linguistic needs of membership.

• Familiarity and respect for special social needs of Medi-Cal populations.

• Knowledge of Medi-Cal and Medicare program(s) eligibility requirements and familiarity with services available through community based ethnic service and advocacy organizations throughout San Diego preferred.

• Bilingual English/Spanish, English/Vietnamese, or English/Arabic.

• Excellent communication and interpersonal skills.

• Ability to exercise mature and independent judgment.

PHYSICAL REQUIREMENTS

• Prolonged periods of sitting.

• Extensive use of telephone.

• Will be required to work evenings and/or weekends.

Must have current authorization to work in the USA

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and trainings. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action.