Customer Success Quality and Performance Specialist

About the Company 

Antidote Health is a tech-driven health insurance company on a mission to make healthcare easy, accessible, and more affordable. We’re rethinking how healthcare works—using technology to remove the friction, complexity, and delays that define the traditional system. Instead of navigating paperwork, long waits, and disconnected experiences, we’re building a simpler, more connected way for people to get care.  

Our platform combines health coverage, virtual care, and a modern member experience into one seamless system designed to help people actually use their benefits.  

We offer Affordable Care Act (ACA) health plans in Arizona and Ohio, and we’re growing quickly. We’re building a company focused on solving real problems—with real impact on people’s lives.

Position Overview

The Customer Success Quality and Performance Specialist evaluates how effectively and accurately Antidote Health serves members, brokers, providers, patients, and internal partners. The position reviews customer interactions and casework against approved quality, service, accuracy, privacy, and compliance standards and translates findings into actionable insight for operational leaders, Training, Compliance, and process owners.

This role administers assigned components of the Customer Success quality program, including interaction evaluation, sampling execution, calibration, reporting, dispute coordination, scorecard maintenance, and quality-record governance. The Specialist helps identify member-experience breakdowns, compliance exposure, performance gaps, and systemic issues before they become larger operational problems.

The position supports Tier 1 Member Services, Tier 2 Customer Success Operations, and Tier 3 Customer Advocacy and Regulatory Affairs. Success requires objectivity, healthcare and regulatory aptitude, analytical discipline, sound judgment, and the ability to distinguish individual performance issues from broader training, content, process, system, staffing, or policy problems.

Antidote Health's mission is to redefine healthcare by providing affordable, high-quality, accessible care and insurance products. The Customer Success organization supports that mission by making healthcare easier to understand, easier to access, and easier to navigate for members, brokers, patients, providers, and internal partners.

Key Responsibilities

• Evaluate voice, chat, email, outbound, and case interactions across assigned Customer Success teams using approved quality scorecards and documented evaluation standards.

• Assess information accuracy, identity verification, privacy, communication, service behaviors, documentation quality, resolution, escalation, and adherence to approved procedures.

• Document findings objectively, including the specific interaction evidence, observed behavior, applicable standard, and resulting score.

• Deliver timely, behavior-based feedback that operational leaders can use for coaching without reconstructing the original evaluation.

• Maintain evaluation consistency across employees, teams, tiers, channels, shifts, tenure groups, and case types.

• Administer a documented sampling model that combines representative random selection with risk-based, targeted, exception-based, and early-tenure review.

• Monitor evaluation coverage across channels, tiers, tenure groups, shifts, case types, and identified risk areas.

• Clearly distinguish randomly selected evaluations from targeted reviews, complaint investigations, regulatory reviews, and other exception-based evaluations.

• Recommend sampling changes when volume, risk, operating structure, technology, or member-contact patterns change.

• Apply approved critical-error and automatic-fail standards consistently, including unauthorized PHI disclosure, material identity-verification failure, member-harm risk, missed regulatory rights, and other defined events with significant compliance, financial, access, or safety impact.

• Evaluate the intake, routing, communication, documentation, and timeliness components of appeals, grievances, complaints, and other regulated casework against approved standards.

• Refer clinical determinations, medical-necessity decisions, legal interpretations, and formal compliance conclusions to the designated accountable function.

• Escalate potential privacy, security, fraud, waste and abuse, regulatory, or member-harm risks through approved channels and within required timeframes.

• Facilitate and participate in calibration sessions with QA, Team Leads, Managers, Training, Compliance, and subject-matter experts.

• Measure scoring consistency and inter-rater reliability using the approved methodology.

• Investigate scoring variance outside approved tolerance and recommend clarification, retraining, or scorecard changes.

• Document calibration decisions and incorporate clarified guidance into evaluation standards and future scoring.

• Maintain version-controlled scorecards, behavioral definitions, evaluation guidance, and effective dates.

• Recommend updates to scorecard criteria, weighting, behavioral definitions, and critical-error standards based on quality findings, business priorities, regulatory changes, and member outcomes.

• Follow established review and approval processes before scorecard changes are published or applied.

• Partner with employees, Team Leads, Operations, Training, Compliance, and other stakeholders to ensure quality standards are clear, observable, and operationally relevant.

• Support periodic reviews to determine whether the scorecard continues to measure the behaviors and outcomes that matter to members and the organization.

• Administer the quality-evaluation dispute process, including intake, documentation, initial review, and communication of outcomes.

• Correct factual, administrative, or scoring errors when evidence supports a change.

• Escalate unresolved disputes to an independent evaluator, the Enablement Manager, Compliance, or another designated authority based on the nature of the disagreement.

• Track dispute themes and recommend improvements when disputes reveal unclear criteria, inconsistent guidance, process defects, or training gaps.

• Build and maintain quality reporting at the individual, team, tier, channel, tenure, and program levels.

• Analyze evaluation results to identify patterns, root causes, emerging risks, and improvement opportunities.

• Distinguish individual performance issues from systemic content, training, process, system, staffing, or policy problems.

• Route findings to the accountable owner and track significant issues through acknowledgement and corrective-action planning.

• Partner with Analytics and operational leadership to examine relationships between quality results and repeat contacts, first-contact resolution, complaints, member satisfaction, and other relevant outcomes.

• Present quality findings and recommendations clearly to operational and executive audiences.

• Provide Team Leads and Managers with evidence-based quality findings that can be translated into focused coaching.

• Partner with Training to identify recurring learning needs and design targeted interventions.

• Evaluate subsequent interactions to determine whether coaching or training improved the targeted behavior.

• Increase review coverage for employees in nesting and early tenure and communicate readiness signals and risks to Training and operational leadership.

• Maintain clear boundaries between QA evaluation, leader-owned coaching, and Operations-owned performance management.

• Support automated and AI-assisted scoring by translating approved criteria into observable, machine-evaluable behaviors.

• Audit machine-generated evaluations against qualified human review and monitor accuracy, false positives, false negatives, drift, and unintended bias across teams, channels, languages, accents, and interaction types.

• Ensure consequential machine-generated findings receive qualified human review and are not used as the sole basis for employment action.

• Document model limitations and escalate material concerns to the Enablement Manager, Compliance, Technology, or the applicable vendor.

• Use speech, text, and interaction analytics to identify trends and prioritize human review where those tools are available.

• Maintain complete, accurate, version-controlled, and audit-ready quality records in accordance with company retention requirements.

• Protect PHI and other confidential information in evaluations, reports, calibration materials, dashboards, and shared examples.

• Use approved access controls, de-identification methods, and secure collaboration practices when sharing quality evidence.

• Perform other related duties consistent with the purpose and level of the position.

Qualifications

Required

• One or more years of quality assurance, quality monitoring, auditing, performance analysis, or comparable evaluation experience in a contact center or regulated service environment.

• Demonstrated experience evaluating interactions using defined quality standards and documenting evidence-based findings.

• Experience leading or actively participating in calibration and resolving scoring differences.

• Experience with at least two of the following: sampling administration, scorecard development, quality reporting, root-cause analysis, regulatory quality review, or automated QA validation.

• Strong analytical and data-literacy skills, including trending, segmentation, and basic descriptive analysis.

• Experience with a quality-management, call-recording, CRM, interaction-capture, or reporting platform.

• Strong written and verbal communication skills and demonstrated consistency, fairness, confidentiality, and impartiality.

• Ability to manage multiple evaluation, reporting, and escalation deadlines without sacrificing accuracy.

• High school diploma, GED, or equivalent required.

Preferred

• Experience with ACA marketplace plans, member services, eligibility, benefits, claims, billing, prior authorization, appeals, grievances, telehealth, or third-party administration.

• Experience evaluating regulated healthcare casework against CMS, state Department of Insurance, accreditation, or internal compliance standards.

• Experience with Five9, Salesforce, healthcare claims or care-management platforms, knowledge-management systems, or contact-center reporting tools.

• Experience with quality-management, speech-analytics, or AI-assisted scoring platforms such as Five9, NICE, Verint, Calabrio, Scorebuddy, MaestroQA, Observe.AI, or a comparable product.

• Experience designing or materially revising a quality scorecard, including behavioral definitions, weighting, and critical-error standards.

• Experience auditing automated quality scores or using interaction analytics.

• Prior frontline, team-lead, training, workforce-management, compliance, or contact-center operations experience.

• ASQ, Lean Six Sigma, COPC, CCXP, healthcare compliance, or comparable quality or process-improvement credential.

• Bilingual capability aligned with member needs.

• Associate or bachelor’s degree in business, healthcare administration, analytics, communications, or a related discipline preferred. Equivalent relevant experience is accepted in lieu of a degree.

Compensation and Benefits

• Base salary range: $65,000 - $85,000 (commensurate with experience and location)

• Comprehensive benefits package including medical, dental, vision

• 401(k)  

• Paid vacation and sick time and company holidays

Company Standards and Expectations

• Employment is at-will, meaning either the employee or the company may terminate employment at any time, with or without cause, in accordance with applicable law

• Employees are expected to adhere to all company policies, including confidentiality, data protection, and code of conduct

• Responsibilities may evolve based on business needs, and flexibility is expected as the company scales

• Compliance with all applicable federal, state, and local laws and regulations is required

Equal Opportunity Statement

Antidote Health is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other protected status under applicable law.