Quality Assurance Specialist - Grievance and Appeals

Posted 21 Days Ago
Be an Early Applicant
Mason, OH
1-3 Years Experience
HR Tech • Information Technology
The Role
The Quality Assurance Specialist is responsible for resolving complaints and grievances from members and providers, conducting research, and interacting with various departments to ensure compliance with standards. The role involves maintaining documentation, reporting on KPIs, and providing education and assistance to members and providers regarding dispute resolutions and processes.
Summary Generated by Built In

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.

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. 
The Company
HQ: Santa Clara, CA
638 Employees
On-site Workplace
Year Founded: 2009

What We Do

IntelliPro Group Inc. is one of the fastest growing IT services and HR solutions companies in Americas & APAC. We provide comprehensive IT services to help clients with IT Strategic Planning, Implementation, Deployment, IT Support on Artificial Intelligence, Big Data, Cloud Computing, Mobile Application Development, Data Mining and Business Intelligence, Enterprise Data Warehouse, and more.

Besides our established IT services, our new business now is quickly extending to one-stop HR Solution Services, including Oversea Branch Setup Consulting, Compensation & Benefits Policy Consulting, Payroll Management Service, Talent Recruiting, and Employer Branding to satisfy our clients’ fast business expansion requirement.

We have built our business on our company-wide commitment to continually overdeliver on the high expectations of our clients, employees, and business partners. The secret to our success is that our unified team works harder, faster, smarter, and more collaboratively than anyone else in the talent acquisition business. In addition to the immense talent and proprietary technology, IntelliPro Group is proud to offer continual professional development and extraordinary benefits to both consultants and full-time employees.

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