Quality Assurance Analyst – Customer Care

About Capital Rx:

Capital Rx is a next generation pharmacy benefits manager, overseeing prescription benefit plans on behalf of employers,unions, and government entities. Determined to transform an outdated model, Capital Rx’s mission is to change the way prescription benefits are priced and administered in the US, unlocking enduring social change. Through our platform approach, Capital Rx delivers data-driven insights and actionable strategies that reduce costs, while improving patient outcomes. Our commitment to innovation, technology, and service is the reason why Capital Rx is among the fastest-growing PBMs in the country.

Position Summary:

The Quality Assurance Analyst is responsible for evaluating and improving customer care performance by monitoring call center interactions, developing quality scorecards, and delivering actionable insights. This role ensures adherence to customer service standards, operational procedures, and regulatory requirements while supporting continuous improvement initiatives across the organization.

Position Responsibilities:

• Collaborate with leadership to develop and maintain customer care quality scorecards aligned with departmental standards to evaluate agent performance
• Conduct quality evaluations of recorded and live customer interactions, ensuring scoring aligns with internal Quality Assurance guidelines
• Assess agent adherence to procedures, compliance procedures, service standards, and best practices to ensure effective and efficient customer support
• Facilitate and participate in calibration sessions within internal teams, external partners, and clients to ensure alignment and consistency in scoring
• Support Customer Satisfaction (CSAT) calibration efforts, partnering with clients and operations teams to enhance service quality
• Analyze QA data and reporting to identify trends, uncover improvement opportunities, and deliver actionable insights, trends and agent opportunities
• Provide performance reporting and support to supervisors and call center leadership to drive quality improvements
• Identify training needs through QA evaluations; support new hire onboarding by ensuring clear understanding of quality standards and scoring expectations
• Oversees the end-to-end processing of member complaints and grievances, ensuring accurate documentation, thorough investigation, and resolution within established regulatory, NCQA, and internal service standards.
• Review, document, and research Authorized Representative (AOR) forms in a timely and accurate manner to support compliance and operational efficiency
• Ensure timely and accurate completion of QA reporting and communication requirements
• Maintain strict adherence to all company policies and regulatory requirements, including HIPAA, patient safety, and data security protocols
• Provide operational support by handling inbound or outbound calls as needed to support business demands and service levels
• Report any compliance concerns or policy violations promptly to management
• Perform other duties as assigned by the supervisor or other members of management within the deadlines provided

Qualifications / Profile:

• 4+ years’ experience with call center operations, with at least 2 years of experience with Quality Assurance or training
• PBM or Healthcare call center operations experience preferred
• Bachelor’s degree preferred, or equivalent experience• Knowledge of HIPAA and Privacy Rule regulations
• Knowledge of Medicare
• A self-starter with outstanding customer service skills and dedication to providing exceptional customer care in a changing, fast-paced startup environment
• Demonstrate aptitude to develop processes and coach frontline customer service employees
• Ability to give and receive constructive feedback
• Strong analytical and organizational skills with an ability to carry out responsibilities with little or no supervision