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Senior Quality Assurance Auditor and Trainer-Member Appeals and Grivances

Company: Fallon Health
Location: Worcester
Posted on: April 18, 2019

Job Description:


Primary 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.

* Special projects as assigned by Department Director.


Education, Licenses, certification and experience requirements:

Education: Bachelor s Degree or equivalent experience in managed health care required

License: N/A

Certification: N/A

Experience: Subject matter expert in Appeals & Grievances


* Regulatory and compliance

* Commitment Through Action

* Contributes to Team Performance

* Focus Upon Quality

* Flexible and Adaptive

Additional Performance Requirements:

* Excellent written and oral communication skills (including public speaking and presentation skills)

* Excellent computer skills

* Excellent organizational and analytical skills

* Excellent interpersonal skills

* Excellent problem-solving, conflict resolution and negotiation skills

* Work with compliance of HMO policy and procedure and regulatory requirements

* Legal training/background preferred but not required.

* Ability to protect high degree of confidential/privileged patient and proprietary business information

Fallon Health is an equal opportunity employer. It is very important for us to maintain a consistant hiring process for every candidate. In addition, we are also a government contractor with requirements to report on our Affirmative Action planning. To that end, we require everyone to apply online.

If you do not have access to a computer or need assistance completing the application process, please contact Human Resources at 1-508-368-9893 (TRS 711).

Keywords: Fallon Health, Worcester , Senior Quality Assurance Auditor and Trainer-Member Appeals and Grivances, Accounting, Auditing , Worcester, Massachusetts

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