Remote Quality Assurance Specialist, Grievance and Appeals

Summary

Join our team as a Quality Assurance Specialist - Grievance and Appeals, leading the resolution of member or provider complaints and grievances relative to quality of care, access to care, and benefit determination. This contract role is based in Mason, OH (Hybrid-Remote) with a pay range of $20.00/Hr. - $21.00/Hr.

Requirements

• Proficient with both Word and Excel
• Ability to work effectively on an individual basis or part of a team

Responsibilities

• Serve 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
• 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

Preferred Qualifications

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