Supervisor, Quality Assurance and Utilization

Verida Inc•Villa Rica, GA

39d

About The Position

This position will be a “working” Supervisory role that requires the employee to know and perform all functions of both the Quality Assurance and Utilization Review Specialists roles, as needed, with the primary role of the Supervisor providing leadership support for both teams with and in the absences of the Quality Assurance/Utilization Review Director. In addition, the supervisor will be responsible for training incoming team members in both QA and the UR Departments when needed.

Requirements

1-year minimum experience in Quality Assurance and or the Utilization Review Departments
1 year or more experience in billing for Medicaid/Medicare and or private insurance
2 years or more work experience and or employment in a paid healthcare-related industry
2 years or more supervisory/managerial role in healthcare-related industry
Minimum Associates Degree or higher in a healthcare-related field

Nice To Haves

Knowledge of Medicare and Medicaid, community resources, dialysis, and the nursing home placement process.
Must possess entry to mid-level proficiency in Microsoft Word and Excel.
Excellent written and verbal communication skills.
Possesses and demonstrates multi-tasking skills in a high-stress environment while working with multiple internal departments, as well as external entities.
Analytical thinker with good judgment.
Well-organized, self-directed individual, who is flexible and takes direction well.
Possesses a high level of interpersonal skills to handle sensitive and confidential situations.

Responsibilities

Receiving, investigating, compiling, and reporting transportation complaints, as well as those related to Medicare Client Grievances for Centene and WellCare.
Reviewing Inquiries DCH North | DCH Atlanta
Closing Inquiries DCH North | DCH Atlanta
Reviewing Grievances for Medicare Clients: Centene and WellCare
Closing Grievances for Medicare Client: Centene and WellCare
Sending RFEs (Request for Explanation) to transportation providers
Mastery of various applications: InSight, Provider Portal, Lyft Concierge, Verida
Coverage of the Atlanta QA Voicemail Box
Assigning members to MCA (Member Care Advisory) List and updating this information via InSight
Sending Productivity Report at day’s end
MCA Trip Monitoring
MCA Documentation via trip notes, manifest notes, member main file notes
MCA Workflow
DCH Trip Monitoring and Reporting
Emailing MCA Same Day | MCA Next Day Reports
Reviewing and making approval/denial determinations for all member transportation requests that are outside of the geographical mileage guidelines and reviewing requests to non-covered Medicaid services and or locations.
Responsible for reviewing and making approval/denial determinations for facilities wishing to participate in the organization’s Subscription/Standing Order Transportation Program.
Responsible for reviewing Subscription/Standing order transportation requests from approved facilities for NEMT.
Investigates transportation provider complaints lodged against Medicaid members during transportation and issuance of Member Warning Letters as warranted.
Responsible for completing the three departmental reports: daily denial letters, member no-show letters, and monthly denial summary.
Monthly Denial Summary Report: This report is pulled and sent to DCH of all types of transportation denials for each region (Atlanta and North).