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