QI Grievance Coordinator

Regal Medical Group•Los Angeles, CA

10d•$23 - $25

About The Position

Under the supervision and direction of the QI Director, the QI Coordinator will perform all clerical and administrative services as assigned. The QI Coordinator provides administrative support to the QI Department completing assignments thoroughly and accurately within assigned timeframes. The QI Coordinator must have excellent reading comprehension skills in order to analyze and process the issues presented. Is detailed in obtaining the applicable medical records and clinical criteria or benefits and facilitates data within regulatory deadlines. Behaves in a professional manner when frequently interfacing with Medical Directors, Case Managers, and internal or external customers. Prepares the initial Grievances for the grievance team. Documents cases in department databases according to established requirements, thoroughly, timely, and accurately while meeting departmental production goals and thresholds. Is able to work independently; but with supervision. Knowledge of contracted health plans. Has a strong professional writing skill that is grammatically correct with ability to clearly and concisely convey complex information. Will demonstrate excellent organizational and time management skills and handles all materials in a confidential manner and accurate way in order to minimize errors. The role of the QI Coordinator is to promote and support the quality and cost effectiveness of quality management across Regal Medical Group and affiliate companies, using Access Express/EZ-CAP/NextGen/Crystal Reports/Heritage Connect.

Requirements

Minimum High School graduate
Minimum one (2) year of Quality Improvement experience.
Computer literate in work, excel.

Nice To Haves

Three to five (3-5) years of managed healthcare experience preferred.

Responsibilities

Provide support to the grievance team in day to day operations.
Timely prepare the grievance cases for the grievance team.
Review incoming grievances and request the necessary information from the providers, ensuring timely follow up if applicable.
Thoroughly, accurately, timely documents and logs inquiries, grievances, and other information into the QI Department databases with minimal errors.
Understands the application of regulatory timeframes as it applies to appeals and grievances and other QI assigned activities.
Assembling, compiling, locating, and maintaining department files promptly to meet deadlines.
Makes and receives telephone calls using proper phone etiquette.
Ability to manage a heavy workload with frequent interruptions and changing priorities in a fast-paced environment while ensuring completeness of all work in a timely manner.
Working as part of a team, collaboration with Medical Directors, Network physicians and staff with ability to establish and maintain cooperative working relationships, and follows through on commitments.
Knowledge of medical information and terminology.
Skill in working independently, but with supervision.
Understands all aspects of the functionality of Access Express/EZ-CAP, Crystal Reports with respect to quality management appeals & grievances.
Complete and assigned tasks accurately and within specified time limits.
Maintain smooth working relations with co-workers and supervisors. Be a “Team Player”.
Excellent verbal and written skills in order to clearly convey complex information, or ideas to Medical Director and other internal and external customers (i.e., health plan representatives).
Ability to speak to individuals using appropriate grammar and vocabulary to obtain information, explain applicable policy and procedure, when necessary.
Skill in writing grammatically correct letters and in proper business format.
Skill in organizing material and information in a systematic and accurate way to minimize errors.
Ability to maintain confidentiality with sensitive information.
Ability to adhere to Regal Medical Group policies and procedures.
Providing support to the QM Director and QM Manager on clinical and other appropriate activities or projects as assigned.
When identifies a problem, informs supervisor in a timely manner so that the problem can be corrected.
Prepares and maintains records and files which are neat, organized, thorough, and readily accessed.
Filling, faxing, copying & purging of files.
Ability to work business hours with flexibility in order to meet deadlines.
Other duties as assigned.