G & A Quality Specialist

Summary of Position

Maintain the department's quality initiatives along with assisting in the development, implementation and maintenance of the department's quality assurance program. Identify and develop the methodologies for measuring the quality standards, track the department's quality outcomes and provide a standardized report of the results. Review, analyze, and process complaints and appeals related to healthcare benefits, claims, and coverage. Collaborate with various teams, conduct audits, and compile reports on quality metrics. Ensure compliance with regulations and company policies, identify trends and areas for improvement, and contribute to process improvements.

Principal Accountabilities

• Examine grievances and appeals to assess compliance with regulations and internal policies.
• Perform investigations, gather information, conduct research, and analyze supporting documentation to understand the issue.
• Render decisions on grievances and appeals, sometimes in consultation with clinical staff, and communicate the findings.
• Analyze patterns and trends to identify systemic issues within the grievance and appeal process.
• Recommend changes to processes, training programs, and documentation to enhance quality and compliance.
• Prepare for and participate in both internal and external audits related to grievances and appeals.
• Track and report on key metrics related to grievance and appeal handling to drive improvement efforts.
• Clearly explain decisions and findings to stakeholders, including members, providers, and internal teams.
• Maintain knowledge of relevant regulations, policies, and best practices.
• Perform quality audits and file reviews in a professional and confidential manner which includes consistent development, retention and application of EH benefits, contracts and departmental procedures.
• Develop and maintain training materials, CMORE repository and the department process and operations manual(s).
• Maintain accurate daily logs of the files audited/prepares written reports including recommendations for improvement.
• Communicate with management the identification and development of ongoing training or retraining needs/performs training of new staff as required.
• Identify root causes of problems and highlight trends within the department/organization.
• Assist in processing new cases and completing final responses/addendum letters when needed.
• Perform other activities as directed, assigned, or required.