[Hiring] Quality Assurance Specialist @Alignment Health

Role Description

The Quality Assurance Specialist Appeals & Grievances is responsible for ensuring Appeals and Grievances data accuracy, regulatory compliance, and timeliness in accordance with CMS requirements while supporting audits, reporting, training, and quality improvement initiatives to achieve Star Measurement outcomes.

• 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 assists 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 in compliance with the CMS guidelines.
• Produces departmental quality performance reports for management review.
• Manipulates and analyzes data from multiple report sources for quality review.
• Assists with the preparation of audit universes and case samples.
• Identifies 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.

Qualifications

• 2+ years of healthcare appeals & grievances experience, related QA experience, or training/supervisory role.
• 2+ years of managed healthcare experience.
• High School Diploma or GED with relevant work experience.
• Bachelor’s degree in Healthcare, Business, or related field with relevant work experience (preferred).

Requirements

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

Benefits

• Fully remote position.
• Pay Range: $48,373.00 - $72,559.00.
• Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Essential Physical Functions

• While performing the duties of this job, the employee is regularly required to talk or hear.
• The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
• The employee frequently lifts and/or moves up to 10 pounds.
• Specific vision abilities required by this job include close vision and the ability to adjust focus.