Operational Quality Specialist

GENERAL DESCRIPTION: The Operational Quality Specialist is responsible for strengthening quality oversight, vendor performance management, and member experience across the Premium Management Operational Initiatives Unit. This role is critical to ensuring compliance with CMS standards, improving service delivery, and supporting organizational goals related to Star Ratings, member satisfaction, and retention. ESSENTIAL FUNCTIONS: • Monitor and analyze monthly member satisfaction survey results to identify trends, risks, and opportunities impacting vendor performance and overall member experience. • Ensure compliance with Centers for Medicare Medicaid Services (CMS) requirements and Consumer Assessment of Healthcare Providers and Systems (CAHPS) standards related to service quality, member experience, and complaint management. • Identify performance gaps and lead the development of corrective and mitigation action plans in collaboration with vendors and internal stakeholders. • Track, validate, and ensure closure of corrective actions by establishing follow-up processes and confirming effective implementation. • Manage and execute the Quality Assurance (QA) process across all Operational Initiatives projects, including Star Ratings, Health Profile Optimization, and Model of Care (MOC). • Audit the execution of member satisfaction surveys to ensure accuracy, consistency, and adherence to established quality standards and methodologies. • Evaluate vendor service delivery, including the quality of in-home services, to ensure compliance with organizational standards and service protocols. • Conduct on-site assessments of vendor operations, including call centers, to validate adherence to defined service, quality, and experience standards. • Coordinate vendor audits, site visits, and performance reviews to strengthen oversight, accountability, and service quality. • Conduct reassessments to measure the effectiveness of implemented improvements and ensure sustained quality outcomes. • Develop and implement standardized processes, tools, and reporting frameworks to enhance quality monitoring, tracking, and operational efficiency. • Provide strategic recommendations to leadership to optimize vendor performance, improve processes, and drive continuous improvement in member experience and operational outcomes. • Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices. • May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document. MINIMUM QUALIFICATIONS: Education and Experience: Bachelor’s degree in Business Administration, Healthcare Administration, Public Health or related field. At least two (2) years of experience in quality assurance, vendor management, performance metrics, audits, and process improvement methodologies. “Proven experience may be replaced by previously established requirements.” Certifications / Licenses: N/A Other: N/A Languages: Spanish – Intermediate (comprehensive, writing and verbal) English – Intermediate (comprehensive, writing and verbal)