Supervisor, Medicare Member Services - Peak Health

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• Supervises and coordinates the daily operations of a Medicare Member Services call center team. Provides leadership, coaching, and operational oversight to ensure members receive accurate, timely, compliant, and high-quality service. Monitors team performance, call center service levels, quality standards, documentation, and adherence to Centers for Medicare & Medicaid Services (CMS) requirements and organizational policies. Collaborates with internal departments to resolve member concerns, improve processes, and support the successful administration of Medicare Advantage and Dual Eligible Special Needs Plan (D-SNP) products.
• Required Schedule: 12:00 p.m. to 8:00 p.m., Saturday through Wednesday. This schedule is subject to change based on departmental and operational needs.

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 pro