Quality Assurance Specialist - Non Contracted Provider Appeals Orange, CA

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. The Quality Assurance Specialist is responsible for monitoring and evaluating provider appeal processing activities to ensure accuracy, compliance with regulatory and organizational standards, and overall effectiveness, while supporting high-quality service outcomes for out of network providers. Job Duties/Responsibilities: 1. Validates the accuracy of generated provider response letters 2. Stays abreast of current workflow quality assurance measures for accurate external communications 3. Recognizes and identifies possible training issues and error trends; reports findings as required. 4. Ensures HIPAA compliance on all external communications 5. Audits appeal determinations for upheld and overturn determination by internal and external team members 6. Will work closely with leadership for daily / weekly / monthly quality assurance reporting through custom reporting tools 7. Participates in roundtable sessions as needed to review and make recommendations regarding efficiency improvements 8. Assists with the development of training tools in collaboration with the department trainer; assists with departmental training as needed 9. Other duties as assigned. Job Requirements: Experience:

• Required: Minimum of two years of related customer service/telemarketing experience/training; or equivalent combination of education and experience.
• Preferred: Experience related to the Medicare Managed Care industry.

Education:

• Required: High School Diploma or GED.

Specialized Skills:

• Required:
• Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.
• Mathematical Skills: Ability to add and subtract two-digit numbers and to multiply and divide with 10’s and 100’s. Ability to perform these operations using units of American money and weight measurement, volume, and distance.
• Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
• Computer Skills: typing 40+ words per minute.
• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Report Analysis Skills: Comprehend and analyze statistical reports.

Licensure:

• 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 sit; use hands to finger, handle, or feel and talk or hear. 2. The employee is frequently required to walk; stand; reach with hands and arms. 3. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. 4. The employee must occasionally lift and/or move up to 20 pounds. 5. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus. Pay Range: $44,790.00 - $67,185.00 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 [email protected].

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