Appeals and Grievances Quality Assurance and Auditing Specialist II

Appeals And Grievances Quality Assurance And Auditing Specialist Ii

Job Category: Customer Service Department: CSC Appeals & Grievances Location: Los Angeles, CA, US, 90017 Position Type: Full Time Salary Range: $67,186.00 (Min.) - $87,342.00 (Mid.) - $107,498.00 (Max.) Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Appeals And Grievances (A&G) Quality Assurance (QA) And Auditing Specialist II is responsible for assisting the A&G Compliance, Training and QA Manager to develop a successful and cohesive unit with a high level of productivity and focus on implementing, executing, tracking, and assessing targeted and random audits for non-clinical grievance and appeal case documentation. Ensure A&G Non-Clinical staff is following all Regulatory guidelines, internal P&Ps, Desktop Procedures, in a consistent and accurate manner. This position will focus on quality review of non-clinical grievance and appeals cases for all line of business (LOB) to identify areas of improvement to assist the department in increasing positive audit outcomes and improved Customer Service to L.A. Care's membership.

Duties

Focus on quality review of grievance and appeals cases for all LOB to identify areas of improvement to assist the department in increasing positive audit outcomes and improved Customer Service to L.A. Care's membership. Complete and accurate cases logged into the system. Thorough documentation of case investigation and resolution. Ensure that all appropriate correspondence is used for each LOB. Assists in document preparation for regulatory and internal audits. Execute targeted and random audits to ensure that all regulatory guidelines, departmental policies, procedures and standards are being met, as well as the organization's mission. Identify and report deviations in performance in advance and recommend process changes to redirect performance to acceptable levels. Track and trend QA reviews, analyze results from scorecards and recommend quality improvements for the Appeal and Grievances Department. Consistently participate in quality initiatives and special project task forces as deemed necessary. Perform other duties as assigned.

Education Required

Associate's Degree In lieu of degree, equivalent education and/or experience may be considered. Education Preferred Bachelor's Degree

Experience Required

At least 4 years of experience in auditing Appeals & Grievances in a healthcare environment required.

Skills Required

Excellent verbal/written communication skills. Advanced computer proficiency, Word, Excel; and Access. Strong analytical and team building skills. Ability to work effectively with diverse team members. Ability to troubleshoot problem areas, formulate recommendations to improve quality and service delivery, and develop effective system and process improvements. Ability to multi-task and streamline day-to-day operations. Strong interpersonal and organization skills and is expected to work independently within the department's established guidelines, policies and procedures.

Licenses/Certifications Required

Licenses/Certifications Preferred

Physical Requirements

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