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QI Appeals Tech
Regal Medical Group - Los Angeles, CA
posted 2 months ago
About the position
The Appeals Tech QI at Regal Medical Group is responsible for processing appeals in compliance with State, Federal, and NCQA regulations. This role requires excellent reading comprehension and analytical skills to effectively manage appeals, document cases accurately, and collaborate with Medical Directors and Case Managers. The Appeals Tech QI plays a crucial role in promoting quality management and ensuring timely processing of appeals while maintaining confidentiality and professionalism.
Responsibilities
- Process appeals in accordance with State, Federal, and NCQA regulations.
- Analyze and process issues presented in appeals with excellent reading comprehension skills.
- Obtain applicable medical records and clinical criteria or benefits within regulatory deadlines.
- Document cases in department databases accurately and timely while meeting production goals.
- Process Fast Track Appeals for inpatient and SNF appeals, interfacing with Medical Directors and Case Managers.
- Timely processing of credentialing reports including provider data and Quality Management issues.
- Manage a heavy workload with frequent interruptions in a fast-paced environment.
- Collaborate with Medical Directors, Network physicians, and staff to maintain cooperative working relationships.
- Maintain confidentiality with sensitive information and adhere to company policies and procedures.
Requirements
- High school diploma or GED.
- 1-2 years of Quality Improvement experience.
- 3-5 years of managed healthcare experience preferred.
- Proficient in Microsoft Office programs: Excel, Word, PowerPoint, Access, and Outlook.
- Excellent writing skills with the ability to convey complex information clearly and concisely.
- Strong organizational and time management skills.
- Ability to work independently with supervision.
Nice-to-haves
- Experience with Access Express/EZ-CAP/NextGen/Crystal Reports.
- Supervising experience.
- Knowledge of medical information and terminology.
Benefits
- Continuing education credits
- License reimbursement
- Paid holidays
- Health insurance
- Dental insurance
- 401(k)
- Flexible spending account
- Tuition reimbursement
- Paid time off
- Parental leave
- Employee assistance program
- Vision insurance
- Life insurance
- Referral program
