Quality Assurance Specialist-Appeal & Grievance

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

This is a fully remote position.

The Quality Assurance Specialist Appeals & Grievances is responsible for ensuring Appeals and Grievances data accuracy, regulatory compliance, and timeliness in accordance with CMS requirements while supporting audits, reporting, training, and quality improvement initiatives to achieve Star Measurement outcomes.

Job Duties/Responsibilities:

• Monitors timeliness with Appeals and Grievances data, reviews case work end-to-end, ensuring workflow procedures are met to achieve Star Measure goals.
• Analyzes and validates accuracy of Appeals and Grievance data according to plan business and CMS regulatory technical reporting requirements.
• Validates and assists with enforcing that all complaint types (e.g., grievances, appeals, complaints filed with Medicare [CTM], fast tracks, LEP) are processed according to plan procedure and in compliance with the CMS guidelines.
• Produces departmental quality performance reports for management review.
• Manipulate and analyze data from multiple report sources for quality review.
• Assists with the preparation of audit universes and case samples.
• Identify training opportunities and potential system and process improvements relating to appeals and grievance data.
• Assists with training and systems applications User Agreement Testing (UAT).
• Participates in departmental and regulatory compliance audits.
• Maintains confidentiality and Health Insurance Portability and Accountability Act (HIPAA) compliance to ensure Protection of Health Information (PHI).
• Other duties as assigned.

Job Requirements:

Experience:

• Required:

• 2+ years of healthcare appeals & grievances experience, related QA experience, or training/supervisory role.
• 2+ years of managed healthcare experience.

Education:

• Required: High School Diploma or GED with relevant work experience  

• Preferred: Bachelor’s degree in Healthcare, Business, or related field with relevant work experience

Training:

• Required: None

• Preferred:

Specialized Skills:

• Required:

• Possess the knowledge of Appeals and Grievance procedures and the Centers for Medicare (CMS) regulatory compliance guidelines.

• Strong attention-to-detail, analytical, problem solving and critical thinking.
• Knowledge of Medicare Managed Care Plans required.
• Demonstrated knowledge of CMS Reporting (ODAG, Stars Measures, etc.).

Licensure:

• Required: None

• Preferred:

Other:

• Required: None

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.  While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $48,373.00 - $72,559.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com.