Grievance and Appeals QA Specialist in Roseland, NJ at Beacon Health Options

Date Posted: 3/29/2018

Job Snapshot

Job Description


We are currently seeking a dynamic Clinical Appeals Quality Assurance Specialist to join our team at our office in Roseland, NJ.  The Clinical Appeals QA Specialist will be responsible for building customer loyalty by enhancing the service quality of the Appeals departments through monitoring correspondence quality and appeals as well as supporting assigned Managers in staff feedback and development.

Position Responsibilities:

  • Monitor, evaluate and document member/provider appeals, clinical case documentation and resolution letters for designated staff to ensure staff responses meet quality standards and provide Manager/Appeal Coordinators with coaching quality data.
  • Proofread, edit or submit revision requests for Physician Advisor (PA) and Clinical Care Manager (CCM) member statements to support clinical denial and appeal resolution letters.
  • Coordinate the compilation of inquiry monitoring evaluations and efficiency data to prepare for efficient coaching sessions.
  • Update and maintain change controls on Clinical Appeals letter templates as directed by client and area management.
  • Compile summary level coaching and efficiency data in preparation for performance reviews.

Position Requirements:

Education: As Associate’s Degree is required.  A Bachelor’s Degree in English, Journalism or Liberal Arts is preferred.

Licensure:  None required

Relevant Work Experience:   Six years’ experience in healthcare management, operations, appeals/grievances are required.

Knowledge, Skills & Abilities:

  • Analysis and problem solving
  • Interpersonal communication
  • Verbal and written communication


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Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled