Quality Support Analyst / Compliance and Training / Full Time / Kearny Mesa
- Corporate Offices
Shift Start Time:Variable
Shift End Time:Variable
Additional Shift Information:
Weekend Requirements:As Needed
What You Will Do
This position is responsible for intake, logging, tracking, and processing of member clinical and claim appeals, member complaints/grievances, member dismissals, and other quality issues. Initiates and coordinates the review process in conjunction with the Quality Management (QM) Supervisor and QM Analysts. Performs case documentation, research (including requesting medical records), and tracking to ensure timely processing in compliance with SCMG and healthplan timeliness standards. Identifies and refers cases for review by advanced level staff according to SCMG and department guidelines. Processes pre-service member appeals in a timely manner. Primary administrative support to the QM Department Appeals and Grievance Unit including monitoring and distribution of electronic fax documents, telephone triage of healthplan, provider and interdepartmental requests, medical records requests, faxing, and filing. Participates in provider telephonic and site audits of non-clinical regulatory requirements. Responsible for comprehensive case review, research, and initiating actions to resolve member claims and retroactive payment related appeals in accordance with SCMG policies and procedures and in compliance with healthplan, regulatory, and contractual requirements and within required timeframes. Acts as a liaison with SCMG departments, Sharp HealthCare, health plans, and providers as it relates to member clinical appeals related to claims. With oversight of the Quality Analyst Nurse and Quality Supervisor, supports the QM department through reviews of grievances, dismissals, and quality variance issues.
- High School Diploma or Equivalent GED required.
- 2 Years Experience in managed care environment with specific experience related to utilization management or quality management, and claims processing.
- Experience in health plan, state & federal regulatory compliance related to managed care.
Knowledge, Skills, and Abilities
- Coding systems experience.
- Proficient in typing and computer data entry (45 wpm).
- Proficient in use of Microsoft Office Word, Excel, Outlook, and PowerPoint applications required.
- Working knowledge of IDX Referral and Customer Service Modules helpful.
- Ability to learn new computer software and systems.
- Occasional travel between Sharp HealthCare facilities and provider offices; must provide own transportation.
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected classAssociate's Degree; H.S. Diploma or Equivalent
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"After nearly 10 years of working here, it's still one of the hardest jobs I've ever loved. If you find a niche here, you'll be working with some of the smartest in the industry. This is where they'll respect you for thinking outside the box and kindness matters. They expect consistency and hard work, but pay you well to do it."
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