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Appeals Clinical Services Operations Quality Assurance Specialist I

Company

Cambia Health Solutions
Address , Burlington, 98233, Wa
Employment type FULL_TIME
Salary $21.85 - $36.85 an hour
Expires 2023-07-29
Posted at 11 months ago
Job Description
Appeals Clinical Services Operations Quality Assurance Specialist I
Remote within WA, ID, OR, and UT
Primary Job Purpose:
The Clinical Services Operations Quality Assurance Specialist I ensures accurate and timely processing of work generated in Clinical Services Operations related to Utilization Management (UM), provider appeals, member appeals, and grievances by performing audits to validate quality, performance, and service level goals. Maintain quality reporting and provide feedback to staff and management. Provide recommendations to improve quality, timeliness and member experience.
Normally to be proficient in the competencies listed below:
Clinical Services Operations Quality Assurance Specialist I would have a combination of education and experience, including but not limited to 3 years Regence Customer Service or Clinical Services experience with at least 1 year of experience in the work they are performing audits for or equivalent, and/or a high school degree or GED.
Responsibilities:
  • Generates reports as requested by management (i.e., accuracy, quality).
  • Identifies trends in errors and recommends solutions to increase efficiency and quality.
  • May make recommendations and assist in coaching and training employees to ensure quality standards are met.
  • Responds quickly to new instructions and adapts to changes such as contract and/or procedure changes and system upgrades or enhancements.
  • Participates in testing and implementing adjustments to the system or assists in recommending system changes and upgrades.
  • Performs in line editorial audits of written notifications, as necessary, prior to completion and mailing to members and providers to ensure accuracy, content, and timeliness.
  • Upholds regulations from State, Federal, and accrediting bodies regarding quality, content, and timeliness as it relates to the work being audited.
  • Contributes to the efficiency of department by being flexible and cross-trained and may be required to assist with department workload.
  • Completes audit work within internal and external systems to ensure that department procedures are followed and established quality standards are met and documents are in appropriate system.
Minimum Requirements:
  • Appeals and/or compliance background preferred but not required.
  • Strong analytical and problem-solving skills.
  • Ability to work independently, to prioritize work, meet deadlines and achieve operational standards.
  • Intermediate computer skills (e.g. Microsoft Office, Outlook, Internet search) and experience with health care systems and documentation (EMR, billing and claims).
  • Ability to learn Clinical Service Operations processes, workflows, and systems which are used to complete the work to be audited.
  • Ability to work effectively in a team environment, with all levels of staff, and to develop positive working relationships.
  • Excellent oral and written communication skills with the ability to interpret and communicate information, including feedback on errors, with tact, diplomacy, patience, professionalism and confidentiality.
  • Ability to make sound judgments and act in accordance with established policies and guidelines.
  • Demonstrated experience with writing, documentation, and editing.
The base hourly pay range for this job is $21.85 - $36.85/hour, depending on candidate's geographic location.
The annual incentive payment target for this position is 5%.
Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:
  • One-time furniture and equipment allowance for employees working from home
  • Up to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)
  • Medical, dental, and vision coverage for employees and their eligible family members
  • Paid time off varying by role and tenure in addition to 10 company holidays
  • Up to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see our External Total Rewards page.
  • Annual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)
  • Up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email . Information about how Cambia Health Solutions collects, uses, and discloses information is available in our
Privacy Policy
. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our
Careers
site.