Manager - Quality Assurance, Appeals, and Esc

4 weeks ago

King of Prussia, United States CareerBuilder Full time

We are seeking a Quality Assurance, Appeals and Escalations Manager to join the team The Manager Quality Assurance, Appeals, and Escalations will be responsible for the management and development of the Quality Assurance, Appeals, and Escalation staff while continuously enhancing the delivery of customer centric strategies that improve the member experience and employee satisfaction across the Operations Organization. It is imperative that this individual has a deep understanding of all QA functions and has experience in building automated and systematic solutions to solve business challenges.

The successful candidate will lead the quality assurance auditing process across all Operational areas including calls, emails, cases, claims, enrollment, email/phone escalation responses, and telephony system opportunities to improve member customer service over all trending opportunities to improve quality and all forms of member, provider, and client interactions.

In addition, the Manager will lead the Escalations and member/provider Appeals/Grievances functions delivering timely and accurate responses while analyzing the data for trends to identify and recommend opportunities for process improvement.

The individual will work collaboratively with stakeholders to understand all product and project work expectations and will devise and manage operations-wide quality improvement procedures, standards, and control processes. The ideal candidate has previous experience working within a complex environment, is both strategic and detail oriented, with a proven track record as a Quality Assurance leader. The successful candidate will thrive in a fast-paced, nimble, and customer-oriented environment.

Responsibilities:

Directs and provides day-to-day leadership to the Quality Assurance and Appeals & Escalations teams, including coaching and development in one-on-one and group settings.
Exhibits a strong passion for driving high levels of Customer Experience and Customer Satisfaction.
Manages high-level communications with clients and internal leadership on all appeals and escalations from engagement to timely resolution while keeping all stakeholders informed.
Evaluates member, client, and provider appeals, escalations, and complaints to identify root cause(s) and works with applicable department(s) to identify options to resolve and minimize and/or eliminate future occurrences.
Collaborates with the Operations Leadership Team, Corporate Training Team, and other key partners to identify and recommend individual and/or group opportunities for improvement.
Maximizes QA processes to identify key areas of improvement on an individual or group basis and collaborates with Leadership, Corporate Training, and other key partners for process change, coaching, and/or training needs.
Evaluates the effectiveness of both internal and vendor partner quality auditing and processes by administering an audit the auditor program.
Evaluates the effectiveness of the quality assurance process by ensuring the most efficient and correct categories of measurement are being utilized internally across all Operations applications. This includes Salesforce, Telephony platforms, Actisure, ObserveAI, and others, as well as external measurement through Excel and other formats.
Creates and participates in the GSC SOP/SCOP process.
Manages the process to ensure internal and external audits are conducted, tabulated, and reported in designated time frames.
Acts as lead, and coordinates data requests and responses for external facing Operations audits.
Manages and maintains proficiency in company products, services, programs, protocols, regulatory Compliance and Operations procedures acting as the department subject matter expert.
Leads the Medallia close the loop process and utilizes member and client feedback/trending to enhance the Operations value proposition.
Other initiatives and duties as assigned.

Requirements:

Undergraduate degree preferred, or 10 + years of progressive Quality Assurance and Operations equivalent experience.
Managerial experience in Operations Quality Assurance (Customer Service or Claim preferred).
Direct experience in Health Insurance vertical preferred. Strong customer service ethos.
International experience professional or extended personal experience preferred.
Excellent listening, verbal, and written, business communication skills.
Ability to establish and maintain effective working relationships across all levels of the organization.
Strong facilitation, investigative, analytical, and problem-solving skills, as well as excellent organization and time management skills.
Ability to effectively manage projects aligned to improve overall quality program.
Strong collaboration skills and ability to work effectively to develop processes and protocols, and to analyze data and solve problems.
Ability to effectively interact with all levels across the company.
Proficient with Microsoft Office products.
Proficient with SalesForce.
Proficient use and understanding of call center telephony hardware/software applications is a plus.
Having a positive and can-do attitude is a must.
Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).

Working Conditions:

Flexibility to work in an office and/or at-home, remote office environment.
Schedule flexibility is occasionally necessary in this position. Individual may be required to attend key business/departmental meetings and/or perform certain business critical job functions outside of normal working hours.
Must be able to communicate internally and externally through receiving and responding to auditory and visual methods.

Internal Pay Grade: 11

The starting pay for this role is $75,926 to $96,806 based on skill level and experience in a similar role.

This job description reflects managements assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned.
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