Quality Assurance Specialist / Job Req 1006959311

Quality Assurance Specialist / Req 1006959311

Hybrid: Applicants must be a California resident as of their first day of employment.

PRINCIPAL RESPONSIBILITIES:

Under general guidance from the Grievance and Appeals Leadership, the Quality Assurance Specialist, is responsible for running reports and assessing the quality of work completed by Grievance and Appeals staff. The Quality Assurance Specialist will prepare, complete, and review G&A reports, listen to calls, and audit paper and electronic case files to assist in continuous training and provide accurate reports to meet the department's requirements.

Principal responsibilities include:

• Assess the quality of documentation, member letters/correspondence, appropriate handling, and timeliness of actions of cases to ensure problem resolution.
• Collect and analyze case quality to develop and maintain G&A training curriculum, clearly identifying training module content, learning objectives, and training/job aids.
• Assist in the training and coaching of staff towards meeting and exceeding performance expectations for quantity, quality, timeliness, and efficiency.
• Assess the intake and quality of phone-based service through the review of recorded calls and actions taken (or not taken) by Grievance and Appeal Coordinators.
• Report quality findings to Sr. Manager, Grievance and Appeals for further action.
• Run standard and ad hoc reports and analyze data to report to DMHC, DHCS, JOM, and Alliance Sub-Committees.
• Collaborate with Analytics department to build reports for internal quality monitoring and/or in response to new state and federal requirements.
• Discuss any issues with G&A leadership team and conduct interventions as needed to ensure cases are resolved timely and appropriately.   
• Conduct internal quality audits to ensure operations are in compliance with all regulations, standards, policies and procedures.
• Collaborate with G&A leadership team to identify staff training and development needs for improved performance. Prepare and submit audit reports to the Sr. Manager, Grievance and Appeals.
• Support continuous improvement of operations between clinical and non-clinical staff through the development, evaluation and refinement of policies and procedures that meet the operational and regulatory goals and requirements.
• Deliver training sessions to clinical and non-clinical staff as needed to inform staff on new policies, procedures, systems, requirements, and continued quality improvement on operational functions.
• Participate in preparation of audits by DMHC, DHCS, NCQA, and Alliance Compliance department.
• Provide back up support to G&A Lead when needed.
• Have complete knowledge of the G&A application system and work with IT to identify areas of improvement and changes to the G&A application as needed.
• Assist in the handling of complex G&A cases and inquiries and collaborate with other departments to resolve member grievances.
• Perform other duties and special projects as assigned.

ESSENTIAL FUNCTIONS OF THE JOB

• Ensure quality audits are done in a timely manner and at an appropriate volume.
• Complete reports and communicate findings in an accurate and timely manner.
• Monitor the Grievance and Appeal Application and ensure appropriate use.
• Collaborate with G&A staff and other departments to continuously improve operational performance.
• Telephone usage and ongoing data entry.
• Participate in departmental and non-departmental meetings and other scenarios.
• Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS

• Constant and close visual work at desk or computer.
• Frequent sitting and working at desk.
• Frequent use of headset.
• Constant data entry using keyboard and/or mouse.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders, files, and other objects weighing between 0 and 30 lbs.
• Frequent walking and standing.
• Occasional need to stand for one to two hours at a time to deliver training to large groups. 

Number of Employees Supervised: 0

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• High school diploma or equivalent experience.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Two years of experience of handling and completing grievance and appeals.
• Two years of experience assessing the performance of others and providing individual feedback preferred.
• Two years of experience in managed care setting; Medicare/Medi-Cal experience preferred.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Excellent oral and written communication skills.
• Excellent analytical and database management skills.
• Leadership and team development skills.
• Ability to develop simple but effective reports.
• Ability to represent organization and department well.
• Strong business acumen.
• Proficient in use computer software programs including Microsoft Office suite, particularly Excel. 

SALARY RANGE: $34.80 - $52.21 Hourly

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.