Appeals Grievances Quality Technician

Position Summary:

The Tech Appeals & Grievance QI under the supervision of the QI Department Manager, processes Appeals and Grievances in accordance with State, Federal, and NCQA regulations. The Tech Appeals & Grievance QI has excellent reading comprehension skills in order to analyze and process the issues presented. Is detailed in obtaining the applicable medical records and clinical criteria or benefits and facilitates data within regulatory deadlines. Behaves in a professional manner when frequently interfacing with Medical Directors, Case Managers, and internal or external customers. Processes Fast Track Appeals for inpatient and SNF appeals that require timely interface with the Medical Director, Case Managers, and facility. Documents cases in department databases according to established requirements, thoroughly, timely, and accurately while meeting departmental production goals and thresholds. Skill in working independently, but with supervision. Knowledge of contracted health plans. Have strong professional writing skill that is grammatically correct with ability to clearly and concisely convey complex information. Will demonstrate excellent organizational and time management skills and handles all materials in a confidential manner and accurate way in order to minimize errors.

Essential Duties and Responsibilities include the following:

• Ability to use analytical skills to formulate logical solutions, but with supervision.
• Thoroughly, accurately, timely documents and logs inquiries, appeals, grievances, and other information into the QI Department databases with minimal errors.
• Understands the application of regulatory timeframes as it applies to appeals and grievances and other QI assigned activities.
• Timely processes Appeals, including Fast Track Appeals/SNF/Acute, which includes review of applicable benefits, claims, denial reasons, authorizations, eligibility, and discusses with Medical Director for decisions on reconsiderations or overturns.
• Ability to manage a heavy workload with frequent interruptions and changing priorities in a fast-paced environment.
• Skill in working as part of a team, collaboration with Medical Directors, Network physicians and staff with ability to establish and maintain cooperative working relationships, and follows through on commitments.
• Knowledge of medical information and terminology.
• Skill in working independently, but with supervision.
• Ability to manage a heavy workload with frequent interruptions and changing priorities while ensuring completeness of all work in a timely manner.
• Excellent verbal and written skills in order to clearly convey complex information, or ideas to Medical Director and other internal and external customers (i.e. health plan representatives).
• Ability to speak to individuals using appropriate grammar and vocabulary to obtain information, explain applicable policy and procedure, when necessary.
• Skill in writing grammatically correct letters and in proper business format.
• Skill in organizing material and information in a systematic and accurate way to minimize errors.
• Ability to maintain confidentiality with sensitive information.
• Ability to adhere to Regal Medical Group policies and procedures.
• Providing support to the QM Director and QM Manager on clinical and other appropriate activities or projects as assigned.
• When identifies a problem, informs supervisor in a timely manner so that the problem can be corrected.
• Prepares and maintains records and files which are neat, organized, thorough, and readily accessed.
• As a member of the QI Team, strives to meet personal, departmental, and organizational Goals and Targets.
• Travels to meetings as may be necessary to perform QI Department activities.
• Is a key member of the QI Team and maintains good working relationships.
• Completes assignments within specified timelines.
• Filling, faxing, copying, purging of files.
• Ability to work business hours with flexibility in order to meet deadlines.
• All other duties as directed by management.

The pay range for this position at commencement of employment is expected to be between $25 - $27 per hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.

Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Full Time Position Benefits:

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

Education and / or Experience:

• Minimum High School graduate
• Minimum one (1) year of Quality Improvement experience.
• Three to five (3-5) years of managed healthcare experience preferred.
• Proficient in MS office programs: Excel, Word, Power Point, Access and Outlook.
• Typing 30 WPM with accuracy.