Quality Assurance Specialist-Appeals & Grievance at Alignment Healthcare USA, LLC in Orange, California

Job Description:

Position Summary:

Reporting to the Sr. QA Manager, Appeals & Grievances, the role of the Quality Assurance Specialist is critical to the success of Alignment Healthcare in realizing its goals and objectives, ensuring quality and integrity of the Appeals and Grievances data and reporting.

General Duties/Responsibilities (May include but are not limited to):

• Possess the knowledge of Appeals and Grievance procedures and the Centers for Medicare (CMS) regulatory compliance guidelines.

• Monitors timeliness with Appeals and Grievances data, reviews case work end-to-end, ensuring workflow procedures are met to achieve Star Measure goals.
• Analyzes and validates accuracy of Appeals and Grievance data according to plan business and CMS regulatory technical reporting requirements.
• Validates and assist with enforcing that all complaint types (e.g., grievances, appeals, complaints filed with Medicare (CTM), fast tracks, LEP) are processed according to plan procedure and compliance with the CMS guidelines.

• Produces departmental quality performance reports for management review.

• Manipulate and analyze data from multiple report sources for quality review.
• Assists with the preparation of audit universes and case samples.
• Identify training opportunities and potential system and process improvements relating to appeals and grievance data.
• Assists with training and systems applications User Agreement Testing (UAT).

• Participates in departmental and regulatory compliance audits.

• Maintains confidentiality and Health Insurance Portability and Accountability Act (HIPAA) compliance to ensure Protection of Health Information (PHI).

• Other duties as assigned.

Supervisory Responsibilities:

N/A.

Minimum Requirements:

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.

• Minimum Experience:

• 2+ years healthcare appeals & grievances experience, related QA experience, or training/supervisory role.

• 2+ years of managed healthcare experience.

• Education/Licensure:

• Bachelor's degree in healthcare, business, or related field, preferred.

• Other:

• Strong attention-to-detail, analytical, problem solving and critical thinking.

• Knowledge of Medicare Managed Care Plans required.

• Demonstrated knowledge of CMS Reporting (ODAG, Stars Measures, etc.).

• Work 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.

Essential Physical Functions:

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.

• 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.

• The employee is frequently required to walk; stand; reach with hands and arms.

• The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.

• The employee must occasionally lift and/or move up to 20 pounds.

• Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Pay range $23-25/hr

Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.

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