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Remote, Oregon, United States
Remote only
MINIMUM QUALIFICATIONS:
EDUCATION AND EXPERIENCE:
1. High school diploma or equivalent and three (3) years of experience working in a customer service call center environment and four (4) years of experience working in Medicare, Medicare Advantage, CMS, Medicaid, Dual Eligible Special Needs Plans (D-SNP), healthcare compliance, health plan operations, member services, or a related environment
OR
2. Associate’s degree and two (2) years of experience working in a customer service call center environment and three (3) years of experience working in Medicare, Medicare Advantage, CMS, Medicaid, Dual Eligible Special Needs Plans (D-SNP), healthcare compliance, health plan operations, member services, or a related environment.
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Bachelor’s degree in healthcare administration, business administration, management, communications, or a related field.
2. Specialized courses, training, or seminars directly related to Medicare, CMS regulations, managed care, healthcare compliance, call center operations, leadership, or business management.
EXPERIENCE:
1. Two (2) years of experience in healthcare, health insurance, managed care, or Medicare Advantage setting.
2. Two (2) years of experience in a team lead or direct supervisory role overseeing customer service or call center associates.
3. Experience supervising employees in a regulated healthcare, health insurance, Medicare, Medicaid, or managed care environment.
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Supervises the daily activities and performance of Medicare Member Services representatives to ensure the delivery of accurate, timely, professional, and member-focused service.
2. Monitors daily call center operations, including call volumes, service levels, average speed of answer, abandonment rates, schedule adherence, quality results, productivity, and other established performance measures.
3. Ensure representatives provide accurate information regarding Medicare Advantage and D-SNP benefits, eligibility, enrollment, claims, authorizations, provider access, pharmacy coverage, grievances, appeals, and other member-related inquiries.
4. Ensures departmental operations and member interactions comply with CMS requirements, Medicare regulations, Medicaid requirements, HIPAA, organizational policies, compliance standards, and applicable state and federal regulations.
5. Monitors calls, customer relationship management records, and other member documentation to ensure accuracy, completeness, professionalism, and compliance with documentation standards.
6. Ensure a new customer relationship management record or appropriate documented interaction is created for each applicable member contact in accordance with departmental procedures.
7. Identifies training and continuing education needs for new and existing employees based on performance results, quality reviews, regulatory updates, operational changes, and individual development needs.
8. Completes annual performance evaluations, introductory and 90-day reviews, regular one-on-one meetings, and other required employee performance assessments.
9. Keeps staff informed of benefit, process, policy, regulatory, system, and operational changes through regular staff meetings, team huddles, individual communication, training sessions, and email correspondence.
10. Provides timely coaching, counseling, recognition, and corrective action to employees in accordance with organizational performance-management and human resources policies.
11. Coaches and leads employees in adhering to CMS guidelines, Medicare requirements, Medicaid requirements, D-SNP requirements, HIPAA regulations, compliance standards, and approved departmental scripts and procedures.
12. Oversee the use of SharePoint and other approved systems to manage team resources and departmental documentation, including updating shared sites, maintaining current policies and procedures, managing access, and ensuring staff can locate required training and reference materials.
13. Coordinates the timely resolution of member issues with internal departments, including Enrollment, Claims, Pharmacy, Provider Relations, Care Management, Appeals and Grievances, Compliance, Quality, Information Technology, and other applicable business areas.
14. Organizes and prioritizes daily operational responsibilities to achieve optimal productivity, accountability, efficiency, service levels, and member satisfaction.
15. Handles escalated member, authorized representative, provider, or internal staff concerns; investigates the circumstances; ensures appropriate documentation; and recommends or facilitates a timely and compliant resolution.
16. Identifies potential complaints, grievances, appeals, coverage concerns, and compliance issues and ensures they are appropriately documented and referred to the department responsible within required timeframes.
17. Works with the Manager or Director to develop, monitor, and achieve departmental goals, performance standards, quarterly objectives, quality-improvement initiatives, and strategic priorities.
18. Maintains confidentiality and protects members’ personal identifiable information and protected health information when interacting with members, authorized representatives, providers, coworkers, and the public.
19. Demonstrates flexibility in meeting departmental and organizational needs related to changes in call volume, staffing, scheduling, business operations, regulatory requirements, system issues, emergencies, and special outreach initiatives.
20. Maintains current knowledge of Medicare Advantage, Original Medicare, Medicaid, D-SNP requirements, Evidence of Coverage provisions, Summary of Benefits, Annual Notice of Change, member rights and responsibilities, and other applicable plan materials.
21. Demonstrates an understanding of healthcare and health plan operations, including eligibility, enrollment, claims, benefits, provider networks, pharmacy coverage, authorizations, billing, grievances, appeals, and reimbursement-related matters.
22. Ensures staff use approved resources, scripts, workflows, and escalation procedures when assisting members and avoids providing information outside the scope of Member Services.
23. Reviews and responds to operational reports, quality findings, call-monitoring results, member feedback, complaints, and compliance concerns to identify trends and implement corrective or preventive actions.
24. Partners with Quality, Training, and Compliance teams, to develop and deliver training, reinforce performance expectations, and address identified knowledge or process gaps.
25. Supports employee onboarding, system access, training, mentoring, and transition to independent call handling.
26. Manage employee schedules, attendance, timekeeping, paid time-off requests, break and lunch adherence, and staffing coverage to support departmental service-level goals.
27. Participate in the recruitment, interviewing, selection, onboarding, and retention of qualified Medicare Member Services representatives.
28. Promotes a professional, collaborative, inclusive, and accountable work environment focused on member experience, regulatory compliance, continuous improvement, and operational excellence.
29. Performs other duties as assigned by the Manager or Director.
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Ability to sit, stand, walk, and use standard office equipment for extended periods of time.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Standard office environment.
SKILLS AND ABILITIES:
1. Strong knowledge of Medicare Advantage, D-SNP, Medicaid, CMS requirements, and health plan operations.
2. Demonstrated ability to lead, coach, motivate, and develop employees in a fast-paced customer service environment.
3. Ability to monitor and interpret call center performance metrics, quality results, productivity measures, and service-level data to identify trends and opportunities for improvement.
4. Strong decision-making, problem-solving, critical-thinking, and analytical skills, with the ability to assess complex situations and determine appropriate actions.
5. Excellent verbal and written communication skills, including the ability to communicate complex healthcare, Medicare, and regulatory information clearly and professionally.
Additional Job Description:
Supervisor of Medicare Advantage Call Center
- Full-time
- weekend rotation required
Scheduled Weekly Hours:
40Shift:
Varied (United States of America)Exempt/Non-Exempt:
United States of America (Exempt)Company:
PHH Peak Health HoldingsCost Center:
2911 PHH Member Services
