Quality Assurance Specialist - Grievance and Appeals

Job Description

Job Description

Job Title : Quality Assurance Specialist - Grievance and Appeals

Position Type : Contract Role

Duration : 4 months contract

Location : Mason, OH (Hybrid-Remote)

Pay Range : $20.00 / Hr. - $21.00 / Hr

Job Description : GENERAL FUNCTION :

GENERAL FUNCTION :

Responsible for leading the resolution of member or provider complaints and grievances relative to quality of care, access to care, and benefit determination.

MAJOR DUTIES AND RESPONSIBILITIES :

• Member and Provider Complaints / Grievances. Serves as a liaison between provider and member or member’s representative with regard to resolution of Member complaints.
• Conducts research and secures required information, including requesting member records, claims analysis, transaction / event documentation.
• Interact with other departments including Member Services, Claim, and Legal to resolve member and provider complaints and grievances.
• Logs, tracks, and processes complaints and grievances forwarded to the Quality Assurance. Department.
• Reports on KPI’s for department and, as required, for Client’s.
• Maintains all documentation associated with the processing and resolution of complaints and grievances to comply with regulatory and client standards.
• Maintain accurate, complete complaint / grievance records in the electronic database.
• Coordinates Complaint Sub Committee meetings include preparing the agenda, notifying participants, and maintaining minutes of the meeting.
• Meets established quality and productivity standards in all areas of complaints and grievances, including client performance guarantees and any federal and / or state regulations as they relate to complaints and grievances.
• Composes final letters that appropriately reflect the Complaint Sub Committee decision.
• Interacts with members and providers to ensure implementation of the Committee's decision.
• Offers appropriate next steps to all unsatisfied members and assists them with proper filing.
• Based on case analysis and historical resolution precedents, establishes and communicates recommended dispute resolution.
• Develops formal request and response letters and written summaries of cases including the facts of the case, resolution, and directions re.
• Provider education / actions.
• Acts as a member and provider telephone contact for complaint grievances.
• Handles escalated calls from provider and / or members in a professional and courteous manner.
• Constructively challenge existing processes and search for opportunities to improve processes.
• Special Exception Processing : Serve as a liaison between Provider Relations and clients claims department for handling all medically necessary claims (i.

e. medically necessary contact lenses, low vision, medical).

• Compose letter to inform provider of approval / denial of medically necessary claim.
• Log, track and report on all medically necessary claims. Meets established productivity and quality standards.
• Proficient with both Word and Excel.
• Ability to work effectively on an individual basis or part of a team.

Top 3-5 desirable attributes / qualifications :

Desirable attributes :

• Direct Grievance and Appeals experience.
• Experience with Medicaid / Medicare member correspondence.
• Experience with managed vision care and / or insurance.

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