Quality Assurance Specialist - Grievance and Appeals

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: 
 

• 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.

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