Network Quality Coordinator (Hybrid) - 25-04

PriMed Management Consulting•Sacramento, CA

1d•$27 - $30•Hybrid

About The Position

Network Quality Coordinator supports the appeals and grievance process by case intake, prep, response outreach and response tracking. Also supports HRM quality audit efforts. May assist with other Network Quality non-clinical administrative tasks and initiatives.

Requirements

3-5 years in related managed care experience required
Knowledge of Prior Authorization processes and regulatory requirements
High School diploma or GED
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.