G & A Quality Specialist

EmblemHealth

  • New York City, NY
  • $56,160-99,360 per year
  • Permanent
  • Full-time
  • 16 days ago
Summary of PositionMaintain the department’s quality initiatives along with assisting in the development, implementation and maintenance of the department’s quality assurance program. Identify and develop the methodologies for measuring the quality standards, track the department’s quality outcomes and provide a standardized report of the results. Review, analyze, and process complaints and appeals related to healthcare benefits, claims, and coverage. Collaborate with various teams, conduct audits, and compile reports on quality metrics. Ensure compliance with regulations and company policies, identify trends and areas for improvement, and contribute to process improvements.Principal Accountabilities
  • Examine grievances and appeals to assess compliance with regulations and internal policies.
  • Perform investigations, gather information, conduct research, and analyze supporting documentation to understand the issue.
  • Render decisions on grievances and appeals, sometimes in consultation with clinical staff, and communicate the findings.
  • Analyze patterns and trends to identify systemic issues within the grievance and appeal process.
  • Recommend changes to processes, training programs, and documentation to enhance quality and compliance.
  • Prepare for and participate in both internal and external audits related to grievances and appeals.
  • Track and report on key metrics related to grievance and appeal handling to drive improvement efforts.
  • Clearly explain decisions and findings to stakeholders, including members, providers, and internal teams.
  • Maintain knowledge of relevant regulations, policies, and best practices.
  • Perform quality audits and file reviews in a professional and confidential manner which includes consistent development, retention and application of EH benefits, contracts and departmental procedures.
  • Develop and maintain training materials, CMORE repository and the department process and operations manual(s).
  • Maintain accurate daily logs of the files audited/prepares written reports including recommendations for improvement.
  • Communicate with management the identification and development of ongoing training or retraining needs/performs training of new staff as required.
  • Identify root causes of problems and highlight trends within the department/organization.
  • Assist in processing new cases and completing final responses/addendum letters when needed.
  • Perform other activities as directed, assigned, or required.
Qualifications
  • Bachelor’s degree
  • 3 – 5+ years’ experience in a health-related field
  • Additional experience / specialized training may be considered in lieu of bachelor’s degree
  • Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences
  • Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.)
  • Experience with processing member and provider correspondence
  • Working knowledge of NCQA regulations, state, and federal guidelines regarding the processing of member/provider correspondence
  • Ability to analyze complex information, identify trends, and make sound decisions
  • Strong written and verbal communication skills to effectively convey information and recommendations
  • Ability to identify and resolve issues related to grievances and appeals
  • Meticulous attention to detail to ensure accuracy and compliance in all aspects of the role
  • Familiarity with relevant healthcare regulations and compliance requirements
  • Prior experience in healthcare, preferably in appeals and grievances
  • Ability to work effectively with cross-functional teams to address issues and implement improvements
  • Proficiency in using relevant software and tools for data analysis and reporting
Additional Information
  • Requisition ID: 1000002656
  • Hiring Range: $56,160-$99,360
Security DisclosureIf you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) - Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.Pay DisclosureAt EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn't account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.EEOC StatementWe value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.Sponsorship StatementAt EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.

EmblemHealth