Network Quality Coordinator (Hybrid) - 26-74

PriMed Management Consulting•Sacramento, CA

1d•Hybrid

About The Position

We’re delighted you’re considering joining us! At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members. Join Our Team! Hill Physicians has much to offer prospective employees. We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction. DE&I Statement: At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are. We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!

Requirements

3-5 years in related managed care experience required
Knowledge of Prior Authorization processes and regulatory requirements
Ability to work independently as well as in a team environment
Computer experience; proficiency in routine applications such as Word and Excel
Excellent organizational and communication skills
Ability to coordinate effectively with team and meet project timeframes

Nice To Haves

Preferred knowledge of Appeals & Grievances operations
Epic/Tapestry and Salesforce knowledge a plus

Responsibilities

Monitoring of all incoming faxes via electronic fax system (Biscom/Faxcom)
Performs administrative process for all member appeals in Epic authorization system (Tapestry) in accordance with health plan designated time frames (intake, outreach, response tracking)
Performs administrative processes for all member complaints in electronic customer relationship management system (Salesforce) in accordance with health plan designated time frames (case intake, prep, practice outreach, practice response tracking)
Monitoring of all Appeals and Grievance email communications
Monitoring of all Appeals and Grievance phone calls and voicemails
Coordination of all report requests
Monitoring of customer relationship management (CRM) Appeals and Grievances queue via Epic authorization system (Tapestry)
Assists in the development of quality audit tools for non-clinical roles and performs non-clinical audits
May perform additional administrative functions to support Network Quality areas including but not limited to training support and development for non-clinical roles within HRM, compliance corrective action plans, Peer Review Subcommittee.
Establish and maintain effective lines of interdepartmental communication
Exercise professionalism when communicating with senior leadership, outside business partners such as health plans, regulatory bodies, and provider offices.