Quality Assurance Specialist (Enrollment)

The Quality Assurance Specialist – Enrollment reports to the Director of Enrollment or designee. The incumbent is responsible for monitoring and rating the accuracy, compliance, and timeliness of work performed by the Enrollment Department of the Medicare Advantage Plan. This includes auditing paper and electronic enrollment applications, disenrollments, plan changes, cancellations, premium billing, late enrollment penalties (LEP), MSP/OHI validation, authorized representative records, Medicare Prescription Payment Plan (M3P/MPPP) case handling, MARx batch file submissions, and Daily Transaction Reply Report (DTRR) reconciliation, as well as call quality audits of the Enrollment Help Desk against CMS regulations, state requirements, and internal policies. The Specialist also completes monthly Universe audits, prepares Enrollment Data Validation (EDV) sample packets for submission to Medicare's Retroactive Processing Contractor (RPC), and supports RPC dispute and rebuttal activity. The Specialist contributes testing, validation, and operational feedback to the development of audit tools, scorecards, policies, and Quick Reference Guides owned by departmental leadership and Training, and participates in calibration sessions and supporting process improvement that strengthens the quality, compliance, and consistency of service delivery.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Conduct quality audits on enrollment transactions, including enrollments, disenrollments, plan changes, cancellations, and premium billing, to ensure compliance with CMS regulations, state requirements, and internal policies and procedures. Audit paper and electronic enrollment applications for completeness and accuracy, including, but not limited to, member and sales agent signature dates, election period attestations and appropriateness (IEP, ICEP, SEP, OEP, AEP, 5-star, gain/loss SEP), plan selection, and beneficiary information. Audit MSP/OHI validation activity to confirm accurate primary payer information and proper coordination-of-benefits handling. Audit Late Enrollment Penalty (LEP) determinations, attestations, comment-type documentation, and outbound call activity for compliance and accuracy. Audit Medicare Prescription Payment Plan (M3P/MPPP) case handling, including opt-ins, opt-outs, withdrawals, denials, and telephonic enrollment scripting, and the accuracy of related Part D reporting. Audit authorized representative (AOR) records, Out-of-Area and Loss of Special Needs Status case handling, and return mail processing for compliance and accuracy. Audit MARx batch file submissions, including transaction codes (e.g., TC 60, TC 61, TC 73, TC 76), effective dates, and PBP values, prior to release to CMS.

QUALIFICATIONS

Strong knowledge of CMS Medicare Advantage enrollment regulations, including enrollment/disenrollment rules, election periods (IEP, ICEP, SEP, OEP, AEP), MSP/OHI, coordination of benefits, LEP, M3P/MPPP, and DTRR processing. Working familiarity with CMS systems (MARx, ERPT, HPMS OEC Module) and the membership system of record (e.g., HealthSuite or similar system). Experience applying call quality monitoring tools and methodologies, including consistent application of scorecard criteria and participation in calibration practices. Experience preparing CMS-required data submissions, including Enrollment Data Validation (EDV), Part D reporting, and Universe reporting, and supporting RPC dispute activity. Intermediate to advanced knowledge of Microsoft Excel; intermediate knowledge of Microsoft Word and PowerPoint. Strong analytical and problem‑solving skills, with the ability to identify trends, perform root‑cause analysis, and develop actionable recommendations. Strong attention to detail and ability to maintain accurate, complete, and defensible audit records. Excellent written and oral communication skills, including the ability to deliver clear audit findings to staff and to elevate trends and concerns to leadership.

EDUCATION

Bachelor's degree in Healthcare Administration, Business, or a related field, or equivalent combination of training and experience.

WORK EXPERIENCE

Minimum of three (3) years of experience in Medicare Advantage enrollment operations, including hands‑on use of CMS systems. Minimum of two (2) years of experience in a quality assurance, auditing, or compliance monitoring role, preferably within a Medicare Advantage enrollment department. Experience with call quality monitoring is strongly preferred.

LANGUAGE SKILLS

Bilingual English/Spanish fluency. Must be able to read, write, and speak in both English and Spanish, with a strong grasp of medical and insurance terminology in both languages. #J-18808-Ljbffr Leon Medical Centers