Job Summary:

• The Quality Improvement Specialist performs all job duties to the highest level of customer service and assistance to both internal and external customers of Client Medical Foundation.
• This position requires exceptional interpersonal communication, customer service, and organizational skills required.
• The quality improvement specialist is required to meet managed care delegation requirements to ensure compliance with turnaround times for preservice appeals and denial letters.

Job Responsibilities:

• Provides support for Quality Improvement activities, including reviewing and assigning health plan member grievances and appeals to the appropriate team members.
• Facilitate comprehensive research and resolution of QIO appeals, from health plans to ensure regulatory timelines are met.
• Assist in the preparation of denial letter language, ensuring language is at appropriate grade level, has understandable text, appropriate grammar and spelling.
• Provides support for multiple quality projects prioritizing effectively and communicating any issues to supervisor.
• Assists in file preparation for regulatory and compliance audits.
• Communicates effectively both internally and externally.
• Utilize MS Word, Excel, Adobe, Outlook for reporting, documentation, and communication.
• Maintain accurate data entry into systems.
• Other duties as assigned.
• Follows company policies, procedures and directives.

Required Skills & Experience:

• Strong interpersonal communication, customer service, and organizational skills.
• Strong attention to detail, including excellent grammar, punctuation, and written communication skills.
• Computer proficiency in Adobe & Microsoft Office : Outlook, Word, and Excel.
• Knowledge of medical terminology.
• Support QI Nurses, QI Supervisor, QI Manager, and others within the QI Department.
• Provides support for Quality Improvement activities, including reviewing and assigning health plan member grievances and preservice appeals to the appropriate team members.
• Ensure appropriate resolution of QIO requests in a timely and appropriate manner.
• Assist with implementing health plan templates.
• Assist in the preparation of denial letter language, ensuring language is at appropriate grade level, has understandable text, appropriate grammar and spelling.
• Maintain department compliance with all federal, state, local laws, regulations, accreditation, and other related requirements along with all organizational policies and procedures.

Preferred Skills & Experience:

• Two (2) years of experience in Managed Care or provider office.
• Two (2) years of experience in health plan appeals and grievances.

Required Education:

• Minimum high school graduate

Preferred Education:

• Some college