Quality Management Specialist II in Boston, MA at Beacon Health Options

Date Posted: 2/4/2020

Job Snapshot

Job Description

We Help People Live their Lives to the Fullest Potential!

For more than 30 years, Beacon has changed the way people live with behavioral health conditions. Today, we are the undisputed leader in behavioral health management, serving 40 million people across all 50 states. At Beacon, we are committed to delivering a ‘world-class’ candidate experience from the moment you click ‘Apply’! Our goal is to help you reach your fullest potential, while utilizing your talents and expertise to help us deliver on our promise.

Do you have a passion for helping others? If so, we are looking for you!

Beacon is currently seeking a Quality Management Specialist II to join our team at our Boston, MA office. This role is responsible for the processing, tracking and follow up of all Claim Review appeals.

This individual is required to have excellent communication and organizational skills, the ability to work cooperatively with Operations, IT, Staff Physicians, Customer Service, Clinical departments, Claims, and Network Operations leadership, the ability to provide excellent customer service to providers, and the ability to perform in potentially stressful situations, such as state, federal, NCQA, URAC or other regulatory/accrediting agency audits.

What Does a Typical Day Look Like:

  • Maintains systems and processes for the timely and accurate resolution of all medical necessity and administrative denials, including the tracking of information via the Denial Log, sending adverse determination letters to providers, when appropriate, within established time frames, and setting up and maintaining Denial Files.
  • Maintains systems and processes for the timely and accurate resolution of all medically necessary and administrative appeals (as delegated); and ensuring compliance with all relevant regulations, accrediting standards, policies and procedures. 
  • Logs appeals in the appeal log, setsup an Appeal File, coordinates a conversation with the Clinical Leadership for expedited appeals and requesting the medical record, and once received, assigns to an advisor to review. S/he keeps the advisors informed of the required time frames to ensure that decisions are made in compliance with state, federal, NCQA and URAC standards and regulations. Once the appeal decision is made, the appeals coordinator composes a decision letter under the direction of the Director of Utilization Management and Clinical Operations sends to the member and provider, if indicated.
  • Develops subject matter expertise on assigned business
  • The Claim Review Coordinator is responsible for the processing of all administrative appeals and presenting to the Administrative Appeal Committee for resolution
  • Provide problem resolution and immediate feedback for technical questions concerning medical necessity denial and appeals
  • Handle escalated calls and complex cases
  • Assist in the preparation of routine reports and deliverables.
  • Maintains up to date Appeal Logs and Appeal Files that are in compliance with all state, federal, NCQA, URAC and other regulatory agency standards / regulations
  • Provides written and verbal education and training to staff, providers, and members.
  • Generates all reports related to the appeals process.
  • Assists in other quality management projects as required, including corporate audits, accreditation, quality improvement activities, and performance standard teams.
  • Other duties as assigned.

What you Contribute?

Education: A Bachelor's degree is required. Master's degree in business administration, health administration, or health related field is preferred.

Licensure: N/A

Relevant Experience: At least 3 years of mathematical, statistical principals and data analysis is required, preferably in a health science/mental health field is desirable. Experience in managed care with a working knowledge of NCQA and URAC standards are helpful.

Knowledge, Skills & Abilities: 

  • Quality Management experience is preferred; behavioral health managed care experience is preferred.
  • Strong knowledge of mathematical, statistical principals and data analysis
  • Ability to develop, analyze and manage reports
  • Ability to prepare written assessment reports
  • Strong organizational skills with keen attention to detail
  • Ability to interact with peers and other departments with clear, concise communication skills, both verbal and written.
  • Demonstrates strong abilities in handling multiple projects simultaneously and meeting tight deadlines
  • Knowledge of MS Office Suite

What Makes Us Different?

  • Here, it’s not just a job – it’s an opportunity to change lives.
  • Our employees are learners, innovators and original
  • Our mission and values guide the way we treat our members, providers and each other.

What We Have to Offer:

  • Healthcare benefits available starting day 1!
  • Health & wellbeing incentives, such as gym membership reimbursement
  • 401K with company match to help reach your future financial goals
  • Generous PTO, because we know life happens outside of work
  • Tuition reimbursement so you can keep reaching your fullest potential

If Beacon sounds like the place for you, what are you waiting for? Apply with us today to get started!

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

At Beacon Health Options, our candidate's data privacy is a top priority. Our recruiting team conducts all communications using official company email (@BeaconHealthOptions.com). Only candidates who have applied for an open position through our Careers page (careers.beaconhealthoptions.com) will be engaged in our interview process. Beacon conducts all interviews in person or over the phone. At no time during the recruiting process will any Beacon recruiter request any financial or personally identifiable information from you.