Provides support for Quality Improvement activities, including reviewing and assigning health plan member grievances and preservice appeals to the appropriate team members. The quality improvement specialist is required to meet managed care delegation requirements to ensure compliance with turnaround times for preservice appeals and denial letters.
Numbers & Facts
Location
Fountain Valley, CA (Remote)
Salary
$25.26–$28.30 Per Hour
Description
Our client, a Healthcare company, is looking for a Health Plan Appeals and Grievances Specialist for their Fountain Valley, CA location.
Responsibilities:
The Quality Improvement Specialist performs all job duties to the highest level of customer service and assistance to both internal and external customers of client Care Medical Foundation.
This position requires exceptional interpersonal communication, customer service, and organizational skills required.
The quality improvement specialist is required to meet managed care delegation requirements to ensure compliance with turnaround times for preservice appeals and denial letters.
Provides support for Quality Improvement activities, including reviewing and assigning health plan member grievances and appeals to the appropriate team members.
Facilitate comprehensive research and resolution of QIO appeals, from health plans to ensure regulatory timelines are met.
Assist in the preparation of denial letter language, ensuring language is at appropriate grade level, has understandable text, appropriate grammar and spelling.
Provides support for multiple quality projects prioritizing effectively and communicating any issues to supervisor.
Assists in file preparation for regulatory and compliance audits.
Communicates effectively both internally and externally.
Utilize MS Word, Excel, Adobe, Outlook for reporting, documentation, and communication.
Maintain accurate data entry into systems.
Other duties as assigned.
Follows company policies, procedures and directives.
Requirements:
Strong interpersonal communication, customer service, and organizational skills.
Strong attention to detail, including excellent grammar, punctuation, and written communication skills.
Computer proficiency in Adobe & Microsoft Office : Outlook, Word, and Excel.
Knowledge of medical terminology.
Support QI Nurses, QI Supervisor, QI Manager, and others within the QI Department.
Provides support for Quality Improvement activities, including reviewing and assigning health plan member grievances and preservice appeals to the appropriate team members.
Ensure appropriate resolution of QIO requests in a timely and appropriate manner.
Assist with implementing health plan templates.
Assist in the preparation of denial letter language, ensuring language is at appropriate grade level, has understandable text, appropriate grammar and spelling.
Maintain department compliance with all federal, state, local laws, regulations, accreditation, and other related requirements along with all organizational policies and procedures.
Two (2) years of experience in Managed Care or provider office.
Two (2) years of experience in health plan appeals and grievances.