Quality Assurance Specialist

Russell Tobin's client is hiring a Quality Assurance Specialist in Mason, OH

Apply Now!

Employment Type : Contract

Location : Remote (but will assist with mail filing in the Mason building approximately one day every 8 weeks on our rotation) Mason, OH 45040

Schedule : Monday-Friday (may change)

Pay rate : $21.43 / hr

Responsibilities :

• Member and Provider Complaints / Grievances
• Serves as a liaison between providers and members or their representatives for resolution of complaints.
• Conducts research and secures necessary information, including member records, claims analysis, and transaction / event documentation.
• Prioritizes and analyzes member and provider issues, and collaborates with Member Services, Claims, and Legal departments to resolve complaints and grievances.
• Logs, tracks, and processes complaints forwarded to the Quality Assurance Department.
• Reports on KPIs for the department and clients as required and keep accurate and complete complaint / grievance records in the electronic database.
• Coordinates Complaint Sub Committee meetings, preparing agendas, notifying participants, and maintaining meeting minutes.
• Meets established quality and productivity standards, including client performance guarantees and relevant regulations.
• Composes final letters reflecting the Committee’s decisions and interacts with members / providers to ensure implementation.
• Offers next steps to unsatisfied members and assists with proper filing.
• Establishes and communicates recommended dispute resolutions based on case analysis and historical precedents.
• Develops formal request and response letters, summarizing case facts, resolutions, and provider education actions.
• Acts as a telephone contact for complaints and grievances, handling escalated calls professionally.
• Special Exception Processing
• Serves as a liaison between Provider Relations and Client's Claims for medically necessary claims (e.g., contact lenses, low vision).
• Follow up with providers to obtain missing information for clean claims to ensure approval or denial from the Medical Director.
• Composes letters to inform providers of the approval or denial of medically necessary claims.
• Logs, tracks, and reports on all medically necessary claims, meeting established productivity and quality standards.

Requirements :

• Proficient in Microsoft Word and Excel.
• Ability to work effectively both independently and as part of a team.
• Customer Service / escalation experience and strong written communication skills
• General Compliance, HIPAA, Fraud, Waste, and Abuse, Security Essentials, and Introduction to Phishing In addition; Model of Care, ODAG, FSL Fraud Integral Staff training, CA Fair Claims.

Preferred Requirements :

• Direct Grievance and Appeals experience.
• Experience with Medicaid / Medicare member correspondence.
• Experience with managed vision care and / or insurance.
• Associate’s degree is ideal but not required.

Benefits that Russell Tobin offers :

Russell Tobin offers eligible employee’s comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), a 401(k)-retirement savings, life & disability insurance, an employee assistance program, identity theft protection, legal support, auto and home insurance, pet insurance, and employee discounts with some preferred vendors.