Appeals & Grievance, Quality Assurance Specialist

Job Number: 2132

Workplace Type:

Position Title: Quality Assurance Specialist-Appeals & Grievance

External Description:

Appeals & Grievance Quality Assurance Specialist

Summary

Responsible for the data validation of Appeals and Grievance data and reporting accuracy. Ensures compliance with all ODAG, CDAG, and technical reporting requirements with the Centers of Medicare and Medicaid and other regulatory requirements as appropriate.

Essential Duties and Responsibilities
(May include, but are not limited to:)

1. Validates integrity and accuracy of data outputs for all Appeals and Grievance reporting.
2. Prepare and disseminate internal management oversight reports accurately and within required time frames.
3. Work with Compliance and I.T as appropriate, to define parameters for a variety of recurring Grievance and Appeal reports.
4. Develop and automate daily, weekly, monthly, quarterly and annual reports based on parameters/reporting requirements for all markets are appropriate.
5. Implement modifications based on changing business needs or regulatory changes.
6. Manipulate and analyze data from multiple sources to produce end product.
7. Submit all reports in a timely manner.
8. Prepare reports for presentation at various committees (e.g. Medical Services Committee, Executive Board Meetings, Compliance Committee, etc.,).
9. Recognize and identifies possible training issues and error trends and reports findings accordingly to department management.
10. Recognize potential system issues and process improvements relating to grievance/appeal data.
11. Will serve as primary or proxy for any mock audits, and participate in CMS audit sessions.
12. Will provide A&G Coordinator monthly quality performance reports to management.
13. Responsible for ensuring HIPAA compliance to ensure Protection of Health Information.
14. Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.).
15. Perform other duties as assigned by management.

Supervisory Responsibilities

This job has no supervisory responsibilities.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.  Education and/or Experience: Bachelor’s degree preferred; or minimum two years related experience.
2. Certificates, Licenses, Registrations: None required.
3. Other Qualifications:
   1. Previous Appeals & Grievance experience.
   2. Previous HMO call center experience.
   3. Knowledge of Medicare preferred.
   4. Previous experience in Quality Assurance, training, and/or supervisory role, preferred.

Skills and Abilities

1. Language Skills: Ability to read and interpret documents such as CMS reporting requirements and guidelines. Excellent verbal and communication skills, ability to speak effectively before groups of customers or employees of the organization.
2. Mathematical Skills: Ability to add and subtract two-digit numbers and to multiply and divide with 10’s and 100’s. Ability to perform these operations using units of American money and weight measurement, volume, and distance.
3. Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
4. Computer Skills: Experience with MS Access, MS Excel and related systems/applications
5. Other Skills and Abilities:
   1. Strong attention to detail, analytical
   2. Ability to work under pressure and deliver
   3. Ability to work independently
   4. Excellent organization skills, multi-tasks

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
2. The employee is frequently required to walk; stand; reach with hands and arms.
3. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.
4. The employee must occasionally lift and/or move up to 20 pounds.
5. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Working Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. The noise level in the work environment is usually moderate.

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Appeals & Grievance, Quality Assurance Specialist

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].