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Robert Half International Quality Assurance Specialist in LATHAM, New York

Description

The Quality Coordinator I is responsible for the appropriate classification, research, investigation, documentation and response to all 1st level member/provider complaints, grievances and/or appeals. Evaluate origin of complaints and provide appropriate corrective feedback Contact Center Associates. Analyze trends and make recommendations for improvements.

Essential Functions

• Conduct triage administration, research, investigation and documentation of all Level 1 member/provider complaints, grievances, appeals, and ensure accurate coding of cases into department’s database.

• Initiate member, provider and internal departmental outreach (telephone/email/fax) as part of case investigation

• Review Contact Center recorded calls as part of case investigations.

• Work directly with Versant Health Vision’s Medical Director regarding provider and member medically necessary appeals and potential qualify of care challenges.

• Participate in internal appeal committee meetings with members, providers, and clinical staff.

• Use a variety of production reporting tools to ensure casework is resolved timely and accurately.

• Approve resolution actions (additional services, redos, refunds, etc.) within allowed authority and escalate to supervisor for appropriate approval

• Create written acknowledgement and resolutions/determinations and/or partner and provide written investigation summaries to client managers and/or directly with clients as needed.

• Initiate education and feedback to Contact Center associates as a result of root cause analysis, including initiation of corrective actions.

• Consistently achieve standardized departmental production and quality metrics

• Participate in departmental calibration meetings, providing collaborative feedback on case trending and process efficiencies.

• Maintain a working knowledge of Company benefit plans, contracts, provider networks, and departmental policies and procedures.

• Maintain a working knowledge of state and federal compliance regulations.

Requirements

Experience

• One to three (3) years of related experience

• Prior supervisory/team leader experience preferred

Competencies

• detail oriented written and verbal communication and interpersonal skills

• Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.

• Ability to write routine reports and correspondence.

• Ability to speak effectively before groups of customers or Associates of the organization.

• General mathematical skills to include basic adding, subtracting, multiplication and division

• Ability to think logically in following procedures and instructions

• General problem solving abilities

• Exhibit sound and accurate judgment and demonstrate accuracy and thoroughness

OfficeTeam, a Robert Half Company, matches professionals in the administrative field with remote or on-site jobs on a temporary and temporary-to-full-time basis. Whether you're a seasoned administrative pro or starting your career, we have options for you.

Our experienced staffing professionals can promote you to employers and advocate on your behalf. We provide access to top jobs, competitive compensation and benefits, and free online training. For more opportunities, get the Robert Half app and receive instant notifications when our AI matches your skills and experience with jobs.

When you work with us, you’re working with the best. has been recognized as one of FORTUNE’s “Most Admired Companies” every year since 1998 and was named to Forbes’ inaugural list of America’s Best Temporary Staffing Firms.

Questions? Call your local office at 1.888.490.4154. All applicants applying for U.S. job openings must be authorized to work in the United States. Benefits are available to temporary professionals. Visit https://roberthalf.gobenefits.net/ for more information.

© 2020 OfficeTeam. An Equal Opportunity Employer. M/F/Disability/Veterans. By clicking “Apply Now,” you’re agreeing to Robert Half’s Terms of Use (www.roberthalf.com/terms-of-use).

Salary: $17.10 - $19.80 / Hourly

Location: LATHAM, NY

Date Posted: February 9, 2021

Employment Type: Temporary

Job Reference: 02880-0011699951

Staffing Area: Office u0026 Administrative

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