Summary of Position

Maintain the department’s quality initiatives along with assisting in the development, implementation and maintenance of the department’s quality assurance program. Identify and develop the methodologies for measuring the quality standards, track the department’s quality outcomes and provide a standardized report of the results. Review, analyze, and process complaints and appeals related to healthcare benefits, claims, and coverage. Collaborate with various teams, conduct audits, and compile reports on quality metrics. Ensure compliance with regulations and company policies, identify trends and areas for improvement, and contribute to process improvements.

Principal Accountabilities 

Examine grievances and appeals to assess compliance with regulations and internal policies.  Perform investigations, gather information, conduct research, and analyze supporting documentation to understand the issue.  Render decisions on grievances and appeals, sometimes in consultation with clinical staff, and communicate the findings.  Analyze patterns and trends to identify systemic issues within the grievance and appeal process.  Recommend changes to processes, training programs, and documentation to enhance quality and compliance. Prepare for and participate in both internal and external audits related to grievances and appeals.  Track and report on key metrics related to grievance and appeal handling to drive improvement efforts.  Clearly explain decisions and findings to stakeholders, including members, providers, and internal teams.  Maintain knowledge of relevant regulations, policies, and best practices. Perform quality audits and file reviews in a professional and confidential manner which includes consistent development, retention and application of EH benefits, contracts and departmental procedures. Develop and maintain training materials, CMORE repository and the department process and operations manual(s).  Maintain accurate daily logs of the files audited/prepares written reports including recommendations for improvement. Communicate with management the identification and development of ongoing training or retraining needs/performs training of new staff as required. Identify root causes of problems and highlight trends within the department/organization. Assist in processing new cases and completing final responses/addendum letters when needed.  Perform other activities as directed, assigned, or required.

Qualifications 

Bachelor’s degree 3 – 5+ years’ experience in a health-related field Additional experience / specialized training may be considered in lieu of bachelor’s degree Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) Experience with processing member and provider correspondence Working knowledge of NCQA regulations, state, and federal guidelines regarding the processing of member/provider correspondence Ability to analyze complex information, identify trends, and make sound decisions Strong written and verbal communication skills to effectively convey information and recommendations Ability to identify and resolve issues related to grievances and appeals Meticulous attention to detail to ensure accuracy and compliance in all aspects of the role Familiarity with relevant healthcare regulations and compliance requirements Prior experience in healthcare, preferably in appeals and grievances Ability to work effectively with cross-functional teams to address issues and implement improvements Proficiency in using relevant software and tools for data analysis and reporting Additional Information Requisition ID: 1000002656 Hiring Range: $56,160-$99,360