Customer Solution Center Appeals and Grievances Quality Auditing Specialist II

　　Job Category: Customer Service

　　Department: CSC Appeals & Grievances

　　Location:

　　Los Angeles, CA, US, 90017

　　Position Type: Full Time

　　Requisition ID: 10214

　　Salary Range: $67,186.00 (Min.) - $87,342.00 (Mid.) - $107,498.00 (Max.)

　　Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

　　Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

　　Job Summary

　　The Customer Solution Center Appeals and Grievances Quality Auditing (QA) Specialist II is responsible for assisting the Appeal and Grievances Compliance, Training and QA Manager to develop a successful and cohesive unit with a high level of productivity and focus on implementing, executing, tracking, and assessing targeted and random audits for non-clinical grievance and appeal case documentation. Ensure G&A Non-Clinical staff is following all Regulatory guidelines, internal P&Ps, Desktop Procedures, in a consistent and accurate manner.

　　This position will focus on quality review of non-clinical grievance and appeals cases for all line of business (LOB) to identify areas of improvement to assist the department in increasing positive audit outcomes and improved Customer Service to L.A. Care’s membership. This position is responsible for monitoring Appeal and Grievances Specialists, Lead Intake, and Senior Appeal and Grievances Specialists, performance against key performance indicators and recognizes trends that require individual or group retraining. The position conducts/reviews audits and analyzes the data and documentation and provides their input to management for review. In addition, is responsible for review and approval of all member letters prior to issuance.

　　This position facilitates recommendations for the development, review, and revision, as appropriate, of organizational and departmental process flows to ensure compliance with relevant regulatory, organizational and departmental guidelines. Generates results of findings, enhances and analyzes various standard reports related to, but not limited to: quality and accuracy of case documentation. This position will work with department Supervisors, Managers and Director for all problems related to quality improvements as needed to increase staff knowledge of L.A. Care, regulations, and departmental requirements. Compiles and presents quality report cards to measure quality enhancements and disseminates to appropriate parties as needed. This position will keep the QA Manager aware of trends, deficiencies and any potential issues that arise for review and evaluation by the Management Team.

　　Duties

　　Focus on quality review of grievance and appeals cases for all LOB to identify areas of improvement to assist the department in increasing positive audit outcomes and improved Customer Service to L.A. Care’s membership. Complete and accurate cases logged into the system. Thorough documentation of case investigation and resolution. Ensure that all appropriate correspondence is used for each LOB. Assists in document preparation for regulatory and internal audits.

　　Execute targeted and random audits to ensure that all regulatory guidelines, departmental policies, procedures and standards are being met, as well as the organization’s mission. Identify and report deviations in performance in advance and recommend process changes to redirect performance to acceptable levels.

　　Track and trend QA reviews, analyze results from scorecards and recommend quality improvements for the Appeal and Grievances Department.

　　Consistently participate in quality initiatives and special project task forces as deemed necessary.

　　Perform other duties as assigned.

　　Duties Continued

　　Education Required

　　Associate's Degree

　　In lieu of degree, equivalent education and/or experience may be considered.

　　Education Preferred

　　Bachelor's Degree

　　Experience

　　Required:

　　At least 4 years experience in auditing Appeals & Grievances in a healthcare environment required.

　　Skills

　　Required:

　　Excellent verbal/written communication skills.

　　Advanced computer proficiency, Word, Excel; and Access.

　　Strong analytical and team building skills.

　　Ability to work effectively with diverse team members.

　　Ability to trouble-shoot problem areas, formulate recommendations to improve quality and service delivery, and develop effective system and process improvements.

　　Ability to multi-task and streamline day-to-day operations.

　　Strong interpersonal and organization skills and is expected to work independently within the department's established guidelines, policies and procedures.

　　Preferred:

　　Health Plan auditing skills.

　　Licenses/Certifications Required

　　Licenses/Certifications Preferred

　　Required Training

　　Physical Requirements

　　Light

　　Additional Information

　　Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

　　L.A. Care offers a wide range of benefits including

　　Paid Time Off (PTO)

　　Tuition Reimbursement

　　Retirement Plans

　　Medical, Dental and Vision

　　Wellness Program

　　Volunteer Time Off (VTO)