What are the responsibilities and job description for the Quality Assurance Specialist position at Cynet Systems?
Job Description:
Pay Range: $16hr - $21hr
Responsibilities:
Pay Range: $16hr - $21hr
Responsibilities:
- Member and Providers Complaints/Grievances.
- Serves as a liaison between provider and member or member’s 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 client 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.
- Reports on KPI’s for department and, as required, for Client’s.
- 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 Committee’s decision.
- Offers appropriate next steps to all unsatisfied members and assist them with proper filing.
- Based on case analysis and historical resolution precedents, establishes and communicates recommended dispute resolution.
- Develops formal request and response letters and written summaries of cases including the facts of the case, resolution, and directions re.
- Provider education/actions.
- Acts as a member and provider telephone contact for complaint grievance.
- Handles escalated calls from provider and/or members in a professional and courteous manner.
- Constructively challenge existing processes and search for opportunities to improve processes.
- Serve as a liaison between Provider Relations and Eyemed 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.
- Compose letter to inform provider of approval/denial of medically necessary claim.
- Log, track and report on all medically necessary claims.
- Meets established productivity and quality standards.
- Proficient with both Word and Excel.
- Ability to work effectively on an individual basis or part of a team.
- Customer Service/escalation experience.
- Strong written communication skills.
- Direct Grievance and Appeals experience.
- Experience with Medicaid/Medicare member correspondence.
- Experience with managed vision care and/or insurance.
- Associate’s degree is ideal but not required.
Salary : $16 - $21
