Quality Coordinator in Rocky Hill, CT at Beacon Health Options

Date Posted: 5/2/2018

Job Snapshot

Job Description

ABOUT THE POSITION

We are currently seeking a dynamic Quality Coordinator - Complaints & Grievance to join our team at our office in Rocky Hill, CT.  The Quality Coordinator - Complaints & Grievance will be responsible for coordinating the investigation and resolution of complaints, grievances, quality of care, adverse incidents and another concerns received from Partnership members and providers in accordance with policies and procedures established under the Partnership’s contract with the State.  Initiates all correspondence related to administrative and medical necessity denials and coordinates the appeals process.

Position Responsibilities:

  • Coordinates the overall process for logging, tracking, investigating, and resolving member and provider complaints, grievances, and concerns.Additional responsibilities include documenting complaints, contacting members and providers to research complaints, preparing related correspondence, and interfacing with senior management, medical directors and/or regional network managers regarding provider corrective action plans.Proactively identifies issues requiring the attention of the Partnership’s senior management and facilitates their resolution.

  • Coordinates the overall process for quality of care concerns and adverse incidents, which includes logging, tracking and researching the concerns and interfacing with the Medical Directors regarding action steps that need to be taken.Proactively identifies issues requiring the attention of the Partnership’s senior management and facilitates their resolution.

  • Provides data management and reporting support to Quality Operations relative to complaints, grievances, quality of care concerns, and adverse incidents.Manages databases and coordinates improvements with MIS.Produces related reports as scheduled as well as on an ad hoc basis.

  • Coordinates the creation of all denial letters for both administrative and medical necessity denials.Logs and tracks when letters are sent to members and providers.Complies with performance standards set by the contact relative to the issuing of the denial letters and notifies senior management when performance standards are not met.

  • Coordinates the overall process for Administrative and Medical Necessity appeals, to include logging, tracking, and investigating appeal requests.Coordinates with local and National Medical Directors to review Medical Necessity appeal requests.Compiles Administrative Appeal requests with rationales and conducts necessary research in preparation for the Administrative Appeal meetings.Complies with performance standards set by the contact relative to the timeframes within which appeals need to be resolved and notifies management when the timeframes are not met.Proactively identifies issues and/or trends requiring the attention of the Partnership’s senior management and facilitates their resolution.

  • Assists in other quality management projects as required, including national audits, accreditation, quality improvement activities, and performance improvement teams.

Position Requirements:

Education: BA preferred, human service background preferred.

Licensure:  None

Relevant Work Experience:   3 years’ work experience, either in a customer service or in a human service setting

Knowledge, Skills & Abilities:

  • MS Office:Outlook, Word, Excel, PowerPoint, Access

  • Analysis and problem solving skills

  • Interpersonal communication

  • Verbal & written communication skills

  • Collaboration and team-oriented work philosophy

  • Organizational and follow-up skills

  • Ability to balance multiple priorities and manage deadlines

  • Ability to exercise good judgment and discretion

  • Demonstrated ability to interact effectively with a broad cross-section of

    the population, including, but not limited to, senior managers, providers,

    staff, and consumers

  • Strong English language speaking skills

  • A second language is desirable, especially Spanish

TO APPLY

Click below on “Apply for this Position” to create a profile and apply for the position

Beacon Health Options company 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
 

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