Quality Complaint Coordinator - 240002

　　DESCRIPTION/RESPONSIBILITIES:Our organization is looking for dynamic individuals who love to learn, thrive on innovation, and are open to exploring new ways to achieve our goals. If this describes you, we want to speak with you. You can help us achieve our vision to lead nationally in innovating equitable whole- person health.

　　Job Summary  Reporting to the Manager, QM Wellbeing. As part of the Quality Management team, the Quality Complaint Coordinator is primarily responsible for ensuring timely intake, assignment, processing, researching, documenting and responding to member complaints, for PA, NJ, and AHA business. This position is also responsible for entering pertinent information into the designated database, communicating with contracted providers to resolve cases, communicating with QM clinical staff and Plan medical directors, tracking case aging, escalating issues prior to expiration of standard processing timelines, and maintaining compliance with all processing timeframes established by state, Center for Medicare/Medicaid Services (CMS) regulations and associated accreditation requirements (e.g. NCQA) as well as IBC policies and procedures.

　　In addition to their assigned duties, this team is responsible for the timely processing of manual letters for the UM department, Sanction letters, QM CAP letters and Appeal letters. 

　　The Quality Complaint Coordinator has a working knowledge of the quality process to define outcome indicators, assess performance using internal and external goals and benchmarks, conducts root cause analyses and works with departmental and organizational staff to establish interventions.

　　Responsibilities1. To assure compliance with regulatory and accreditation agencies the Quality Complaint Coordinator will be accountable to maintain a current understanding of the regulatory requirements and the accreditation standards to meet or exceed compliance with applicable regulations/standards.2. Investigates and resolves quality of care/service complaints and analyzes associated data to facilitate improvement of member satisfaction of care and/or services provided by the practitioner/provider network.3. Requests, collects and analyzes data to monitor trends and assure compliance with continuity and coordination of care activities conducted by the QM department.4.Requests corrective action plans from network practitioners/providers in response to identified quality of care and/or service determinations.5.Conducts quarterly reviews to assure that documentation in the practitioner/provider file supports the problem/issue identified, that departmental policies and procedures are followed.6.Accountable for the monthly reporting of quality of care and/or service complaints Executive Inquiries to management and senior management staff.7.Creates and maintains desk procedures that documents current departmental processes and practices. Recommends changes to policy and procedure to assure efficient and effective uses of resources.8.Facilitate the transmission if all manual letters for timely and appropriate processing.

　　Experience, Knowledge, & Skills* Exhibits excellent interpersonal skills, including those required for customer service.* Possesses excellent organizational skills and ability to manage demanding workload; self-motivated; able to carry out responsibilities with minimum supervision.* Demonstrated ability to work independently, handling situations that require independent judgment.* Demonstrated ability to manage specialized electronic database and run reports.* Demonstrated ability to interact with diverse groups of people within the organization and with outside agencies.* Possesses the analytical skills necessary to follow up information provided on physician and allied health applications.* Requires ability to pay meticulous attention to detail.* Adheres to professional confidentiality standards in accordan e with legal, ethical, and departmental policies.* Handles sensitive and confidential situations/information with a high degree of tact and diplomacy.* Comprehensive experience with Microsoft Office Suite, excellent organizational, presentation, interpersonal, verbal and written communication skills.   * Bachelor's degree preferred, but not required

　　Equal Opportunity Employer-minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity