Quality Assurance Specialist

4 days ago

Mason, United States Russell Tobin Full time

Russell Tobin's client is hiring a Quality Assurance Specialist in Mason, OH

Apply Now

Employment Type: Contract

Location: Remote (but will assist with mail filing in the Mason building approximately one day every 8 weeks on our rotation) Mason, OH 45040

Schedule: Monday-Friday (may change)

Pay rate: $21.43/hr

Responsibilities:

  • Member and Provider Complaints/Grievances
  • Serves as a liaison between providers and members or their representatives for resolution of complaints.
  • Conducts research and secures necessary information, including member records, claims analysis, and transaction/event documentation.
  • Prioritizes and analyzes member and provider issues, and collaborates with Member Services, Claims, and Legal departments to resolve complaints and grievances.
  • Logs, tracks, and processes complaints forwarded to the Quality Assurance Department.
  • Reports on KPIs for the department and clients as required and keep accurate and complete complaint/grievance records in the electronic database.
  • Coordinates Complaint Sub Committee meetings, preparing agendas, notifying participants, and maintaining meeting minutes.
  • Meets established quality and productivity standards, including client performance guarantees and relevant regulations.
  • Composes final letters reflecting the Committee’s decisions and interacts with members/providers to ensure implementation.
  • Offers next steps to unsatisfied members and assists with proper filing.
  • Establishes and communicates recommended dispute resolutions based on case analysis and historical precedents.
  • Develops formal request and response letters, summarizing case facts, resolutions, and provider education actions.
  • Acts as a telephone contact for complaints and grievances, handling escalated calls professionally.
  • Special Exception Processing
  • Serves as a liaison between Provider Relations and Client's Claims for medically necessary claims (e.g., contact lenses, low vision).
  • Follow up with providers to obtain missing information for clean claims to ensure approval or denial from the Medical Director.
  • Composes letters to inform providers of the approval or denial of medically necessary claims.
  • Logs, tracks, and reports on all medically necessary claims, meeting established productivity and quality standards.

Requirements:

  • Proficient in Microsoft Word and Excel.
  • Ability to work effectively both independently and as part of a team.
  • Customer Service/escalation experience and strong written communication skills
  • General Compliance, HIPAA, Fraud, Waste, and Abuse, Security Essentials, and Introduction to Phishing In addition; Model of Care, ODAG, FSL Fraud Integral Staff training, CA Fair Claims.

Preferred Requirements:

  • Direct Grievance and Appeals experience.
  • Experience with Medicaid/Medicare member correspondence.
  • Experience with managed vision care and/or insurance.
  • Associate’s degree is ideal but not required.

Benefits that Russell Tobin offers:

Russell Tobin offers eligible employee’s comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), a 401(k)-retirement savings, life & disability insurance, an employee assistance program, identity theft protection, legal support, auto and home insurance, pet insurance, and employee discounts with some preferred vendors.

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