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Quality Assurance Auditor - Member Appeals and Grievances

Company: Fallon Community Health Plan
Location: Worcester
Posted on: January 15, 2022

Job Description:

Quality Assurance Auditor - Member Appeals and GrievancesUS-MA-WorcesterJob ID: 6629Type: Full Time# of Openings: 1Category: QualityFallon Health - Corp HQOverviewFallon Health Vaccination Requirements:To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as "Remote" require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment. About Fallon HealthFounded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation's top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org. Brief summary of purpose:The Fallon Health Senior Quality Assurance Auditor and Trainor is an essential function to Fallon Health's compliance with CMS regulations, NCQA standards, other applicable regulatory requirements, and member expectations. The Senior QA Auditor ensures adherence to the Fallon Health Appeals and Grievance process as outlined in the Plan Member Handbook/Evidence of Coverage, departmental policies and procedures, and regulatory standards. The Senior QA Auditor serves to ensure that pertinent data regarding member grievances and appeals is captured and entered into the appropriate IT application, serves as a liaison between systems personnel and end users, provides systems analysis to ensure the needs of the team are met as well as assist in system implementation or training, in compliance with the health plan, governmental and accrediting agency requirements.ResponsibilitiesPrimary Job Responsibilities:Ensure adherence to Fallon Health Standard and Expedited Appeals Processes as outlined in Member Handbook/Evidence of Coverage, and in compliance with applicable NCQA standards, CMS, MassHealth and other state or federal regulatory requirements. Participate in any internal compliance or external CMS audit or state audit. Assist in the development of trending issues. Orients new staff, serving as a preceptor and provides mentoring to new employees on an ongoing basis. Identify training opportunities, individual and team coaching needs and reports findings to senior management. Review case and call documentation for thoroughness and accuracy and recommend and implement training improvement changes. Monitor and manage strict adherence to turn-around times to ensure compliant with business requirements.Conducts audits on a regular basis according to the policies and procedures as assigned by the Director.---Perform root cause analysis to ensure accuracy of departmental processes and identify, when needed, process improvement opportunities.Participates in various meetings as a department representative; acts as a representative on various company wide committees. Dessimates policies and procedure information to staff to ensure successful functioning of the Department.---Research and resolve system-wide issues, deficiencies, problems and formulate quality improvement measures.Identifies service issues and processes that impact member satisfaction and provides input to leadership about the issues.Meet regularly with Department Director and management team to identify and discuss department and/or identified system issues directly effecting member and staff satisfaction to recommend plans for improvement measures and in developing and implementing specific work plans for improvements in department work processes.Has proven competencies in entry level coordinator and Coordinator II position.Back-up support to MassHealth Board of Hearings process.Commands overall understanding of Department goals and processes, including introductory database management and case triage process. Understands interdepartmental processes and relationships.Serves as a resource for high level specialized project work, serves as a liaison between systems personnel and end users, provides systems analysis to ensure the needs of the team are met as well as assist in system implementation or training.Special projects as assigned by Department Director. QualificationsEducation, Licenses, certification and experience requirements: Education: Bachelor's Degree or equivalent experience in managed health care required Experience: Subject matter expert in Appeals & Grievances Competencies:Regulatory and compliance Commitment Through ActionContributes to Team PerformanceFocus Upon QualityFlexible and Adaptive Additional Performance Requirements:Excellent written and oral communication skills (including public speaking and presentation skills) Excellent computer skillsExcellent organizational and analytical skillsExcellent interpersonal skillsExcellent problem-solving, conflict resolution and negotiation skillsWork with compliance of HMO policy and procedure and regulatory requirementsLegal training/background preferred but not required.Ability to protect high degree of confidential/privileged patient and proprietary business informationFallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. PM16PI160578451

Keywords: Fallon Community Health Plan, Worcester , Quality Assurance Auditor - Member Appeals and Grievances, Accounting, Auditing , Worcester, Massachusetts

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