Job Abstract

The Customer Solution Center Appeals and Grievances Quality Auditing (QA) Specialist II is responsible for assisting the Appeal and Grievances 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. This position is responsible for monitoring Appeal and Grievances Specialists, Lead Intake, and Senior Appeal and Grievances Specialists, performance against key performance indicators and recognizes trends that require individual or group retraining. The position conducts/reviews audits and analyzes the data and documentation and provides their input to management for review. In addition, is responsible for review and approval of all member letters prior to issuance.

This position facilitates recommendations for the development, review, and revision, as appropriate, of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational and departmental guidelines. Generates results of findings, enhances and analyzes various standard reports related to, but not limited to: quality and accuracy of case documentation. This position will work with department Supervisors, Managers and Director for all problems related to quality improvements as needed to increase staff knowledge of L.A. Care, regulations, and departmental requirements. Compiles and presents quality report cards to measure quality enhancements and disseminates to appropriate parties as needed. This position will keep the QA Manager aware of trends, deficiencies and any potential issues that arise for review and evaluation by the Management Team.

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.

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

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. 

Preferred:
Health Plan auditing skills.