Remote Quality Assurance Specialist (Medicare Appeal Claims Focus)

• *This role requires an advanced understanding of Healthcare Industry, specifically Medicare/Medicare Advantage related Claims/Appeals review experience. Please apply if you have experience reviewing claims/appeals in accordance with CMS Guidelines** Job Summary We’re looking for a detail-oriented Quality Assurance Specialist to join our team on a full-time, remote basis. In this role, you’ll use your knowledge of Medical Claims/Appeals in accordance with CMS Guidelines for Medicare to evaluate call center interactions to ensure customers receive accurate, compliant, and positive experiences. You’ll monitor performance, provide feedback, and help strengthen training initiatives. This is an excellent opportunity for someone with strong Medicare knowledge and claims/appeals experience who enjoys problem-solving and process improvement. Duties • Review and evaluate inbound/outbound calls for quality, compliance, and service standards in accordance with CMS Guidelines. • Experience reviewing Claims/Appeals for Medicare/Medicare Advantage plans. • Complete evaluation forms and prepare reports on call performance. • Identify trends, training opportunities, and areas for workflow improvements. • Audit call recordings, screen captures, and documentation for accuracy and adherence to guidelines. • Ensure compliance with HIPAA and privacy standards. • Support the development of training materials and assist with coaching sessions as needed. Experience • High school diploma or GED required. • 3+ years of experience working with medical claims/appeals • Prior exposure to healthcare or Medicare call centers is preferred. • Ability to prepare clear reports and analyze call data for performance trends. • Comfortable working in a fast-paced, remote environment. • Proficient typing (40+ WPM) and solid computer skills (MS Office, reporting tools). • Effective written and verbal communication skills with a professional phone manner. Job Types: Full-time, Temp-to-hire Pay: $28.00 - $32.00 per hour Benefits: • 401(k) • Dental insurance • Employee assistance program • Health insurance • Life insurance • Paid time off • Parental leave • Professional development assistance • Vision insurance Application Question(s): • Do you have experience in Medicare Managed Care? Experience: • Managed care: 3 years (Required) Shift availability: • Day Shift (Required) Work Location: Remote Apply tot his job