Claims customer service/Quality Assurance Specialist
Job Description Claims Customer service/Quality Assurance Specialist Duration:
6 Months Hours:
Tuesday - Saturday (8 - 5pm) Location:
Mason, OH - Mostly WFH.
Hybrid of 2 days/week is company policy Top 3-5 mandatory and/or minimum requirements Prior work experience (G&A, claims, appeals, call center, etc.
), Strong written and verbal communication skills, and health claims processing background 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 Providers Complaints/Grievances.
Serves as a liaison between provider and member or members representative with regard to resolution of Member complaints.
Conducts research and secures required information, including requesting member records, claims analysis, transaction/event documentation.
Prioritizes and analyzes member and provider issues and seeks Clients Medical Director involvement as needed.
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 KPIs for department and, as required, for Clients.
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 Serve as a liaison between Provider Relations and Client claims department for handling all medically necessary claims (i.
e.
medically necessary contact lenses, low vision, medical).
Follow up with providers to obtain missing information for clean claim to ensure approval/denial from Client Medical Director.
Responsible for resolution of member and provider complaints and appeals related to quality of care, access to care, and benefit determination.
Facets experience preferred.
Recommended Skills Call Centers Claim Processing Communication Perseverance Quality Management Databases Estimated Salary: $20 to $28 per hour based on qualifications.
6 Months Hours:
Tuesday - Saturday (8 - 5pm) Location:
Mason, OH - Mostly WFH.
Hybrid of 2 days/week is company policy Top 3-5 mandatory and/or minimum requirements Prior work experience (G&A, claims, appeals, call center, etc.
), Strong written and verbal communication skills, and health claims processing background 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 Providers Complaints/Grievances.
Serves as a liaison between provider and member or members representative with regard to resolution of Member complaints.
Conducts research and secures required information, including requesting member records, claims analysis, transaction/event documentation.
Prioritizes and analyzes member and provider issues and seeks Clients Medical Director involvement as needed.
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 KPIs for department and, as required, for Clients.
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 Serve as a liaison between Provider Relations and Client claims department for handling all medically necessary claims (i.
e.
medically necessary contact lenses, low vision, medical).
Follow up with providers to obtain missing information for clean claim to ensure approval/denial from Client Medical Director.
Responsible for resolution of member and provider complaints and appeals related to quality of care, access to care, and benefit determination.
Facets experience preferred.
Recommended Skills Call Centers Claim Processing Communication Perseverance Quality Management Databases Estimated Salary: $20 to $28 per hour based on qualifications.
|
|
 | |
