Customer Engagement and Experience Compliance and Quality Auditor II

L.A. Care Health Plan•Los Angeles, CA

About The Position

The Customer Engagement and Experience Compliance and Quality Auditor II is responsible for evaluating the accuracy, compliance, and quality of customer interactions within L.A. Care’s Customer Engagement and Experience operations. This position conducts targeted audits of member interactions, documentation, and service workflows to ensure adherence to federal/state regulations, Centers for Medicare and Medicaid Services (CMS) and Medicaid requirements, National Committee for Quality Assurance (NCQA) standards, internal policies, and customer service best practices. The Auditor identifies risks, trends, training needs, and opportunities for improvement while supporting regulatory readiness and service excellence initiatives.

Requirements

High School Diploma/or High School Equivalency Certificate
At least 2 years of experience in health plan operations, contact center quality assurance, compliance auditing, or member services.
Experience in managed care customer service or contact center environments.
Strong knowledge of health plan benefits, customer service workflows, and contact center operations.
Familiarity with CMS call monitoring guidelines and regulatory requirements.
Excellent attention to detail and ability to identify compliance and quality issues.
Strong critical thinking, analytical, and documentation skills.
Excellent communication skills, with ability to deliver constructive feedback.
Proficient in QA platforms, CRM systems, and call monitoring tools.
Ability to maintain confidentiality and adhere to HIPAA/privacy standards.
Proficient in MS Office.
Ability to coach and train employees.

Nice To Haves

Associate's Degree
Experience with Medicaid/Medicare/Commercial requirements, CMS contact center standards, and NCQA regulations.
Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.
American Society for Quality - Certified Quality Auditor (ASQ - CQA) Certification

Responsibilities

Evaluates customer interactions across all channels (calls, chat, email, and correspondence) for accuracy, professionalism, empathy, and service quality. Verifies representatives provide correct benefit information, follow call scripts, and use approved language. Reviews documentation to ensure complete, timely, and accurate recording of member interactions. Audits customer interaction records to ensure adherence to CMS guidelines, state Medicaid rules, NCQA standards, Health Insurance Portability and Accountability Act (HIPAA), privacy regulations, and internal compliance policies. Identifies potential compliance risks such as benefit misinterpretations, incomplete disclosures, or policy deviations. Flags issues for corrective action and escalates high-risk findings per protocol. (50%)
Prepares detailed audit reports summarizing findings, trends, error types, and opportunities for improvement. Tracks performance results at the individual, team, and process level. Presents audit insights to leadership. (10%)
Participates in Root Cause Analysis (RCA) for recurring quality issues, compliance gaps, or service failures. Collaborates with internal teams to develop and implement corrective actions. Validates the effectiveness of remediation efforts through follow-up audits. (5%)
Provides feedback to key stakeholders regarding knowledge gaps, script deviations, or policy misunderstandings. Assists in creating or updating Quality Assurance (QA) scorecards, training materials, workflows, and Standard Operating Procedures (SOPs). Participates in calibration sessions to maintain scoring accuracy and consistency. (10%)
Assists with audit readiness for CMS, California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), NCQA, internal audits, and other external oversight bodies. Maintains documentation and evidence supporting compliance with regulatory audit requirements. Supports quality improvement initiatives tied to Consumer Assessment of Healthcare Providers and Systems (CAHPS), Medicare Stars, grievance reduction, call accuracy, and member experience targets. (10%)
Works closely with internal teams to support operational excellence. Serves as a key resource on contact center quality and compliance expectations. (5%)
Performs other duties as assigned. (10%)Duties Continued