Appeals Quality Assurance Specialist
Posted on Nov 15, 2018 by Beacon Health Options
We are currently seeking a dynamic Clinical Appeals Quality Assurance Specialist to join our team in Newark, NJ!
About the Position:
We are currently seeking a dynamic Clinical Appeals Quality Assurance Specialist to join our team in Newark, NJ! The Clinical Appeals Quality Assurance Specialist builds customer loyalty by enhancing the service quality of the Appeals departments through monitoring correspondence quality and appeals as well as supporting assigned Managers in the staff feedback and development processes
- Monitor, evaluate and document member/ provider appeals member/ provider appeals, clinical case documentation, and resolution letters for randomly designated staff to ensure staff responses meet quality standards, and provides Manager/Appeal Coordinators with coaching quality data. Supports assigned Managers to ensure frequent feedback and developmental opportunities are provided to the Clinical Appeals staff.
- Proofread, edit or submit revision requests for Physician Advisor (PA) and Clinical Care Manager (CCM) member statements to support clinical denial and appeal resolution letters.
- Coordinate the compilation of inquiry monitoring evaluations and efficiency data to prepare for efficient coaching sessions. Provide Appeal Coordinators with scorecards and action plan for process improvement if needed.
- Update and maintain change controls on Clinical Appeals letter templates as directed by client and area management.
- Compile summary level coaching and efficiency data in preparation for performance reviews.
- Audit the timeliness and accuracy of both written and telephonic inquiry/appeal resolution requests made by Appeal staff, as appropriate.
- Recommend process improvements or training opportunities to improve overall service quality by identifying trends in inquiry monitoring.
- Assure integrity and confidentiality of appeal documentation and quality results.
- Participate in regular Appeal Quality Assurance team meetings to generate ideas for performance improvement, service delivery, and cross-functional initiatives that contribute to department success.
- Maintain compliance with NCQA, URAC, client performance guarantees, Service Level Agreements and regulatory guidelines that govern the Appeals process. Respond to monthly errors identified by Quality Management and submit corrective action plans.
- Complete projects and other research tasks as assigned by area management.
- Education: Associate's Degree is required, Bachelor's degree in English, Journalism, or Liberal Arts is preferred
- Relevant Work Experience: 2 years of experience an audit, data analyst or quality role in a health insurance/healthcare setting is required
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Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled
AAP Reporting Location:
NJ - Roseland
ID (Req #):
40 hours per week