Job Description

The Appeals Tech QI under the supervision of the QI Department Manager processes Appeals in accordance with State, Federal, and NCQA regulations. The Appeals Tech QI must have excellent reading comprehension skills in order to analyze and process the issues presented. Is detailed in obtaining the applicable medical records and clinical criteria or benefits and facilitates data within regulatory deadlines. Behaves in a professional manner; when frequently interfacing with Medical Directors, Case Managers, and internal or external customers. Processes Fast Track Appeals for inpatient and SNF appeals that require timely interface with the Medical Director, Case Managers, and facility. Documents cases in department databases according to established requirements, thoroughly, timely, and accurately while meeting departmental production goals and thresholds. Is able to work independently; but with supervision. Knowledge of contracted health plans, benefits and claims. Has a strong professional writing skill that is grammatically correct with ability to clearly and concisely convey complex information. Will demonstrate excellent organizational and time management skills and handles all materials in a confidential manner and accurate way in order to minimize errors.

The role of the Appeals Tech QI is to promote and support the quality and cost effectiveness of quality management across Regal Medical Group and affiliated companies, using Access Express/EZ-CAP/NextGen/Crystal Reports/Heritage Connect.

1. Ability to use analytical skills to formulate logical solutions, but with supervision.
2. Thoroughly, accurately, timely documents and logs inquiries, appeals and other information into the QI Department databases with minimal errors.
3. Understands the application of regulatory timeframes as it applies to appeals grievances and other QI assigned activities.
4. Timely processes Appeals, including Fast Track Appeals/SNF/Acute which includes review of applicable benefits, claims, denial reasons, authorizations, eligibility, and discusses with Medical Director for decisions on reconsiderations, overturns or corrective actions as applicable.
5. Timely processing credentialing reports that include provider data of grievances, medical record review, site audit, member satisfaction, Quality Management issues and Utilization Management Issues trends.
6. Ability to manage a heavy workload with frequent interruptions and changing priorities in a fast-paced environment while ensuring completeness of all work in a timely manner.
7. Working as part of a team, collaboration with Medical Directors, Network physicians and staff with ability to establish and maintain cooperative working relationships, and follows through on commitments.
8. Knowledge of medical information and terminology.
9. Skill in working independently, but with supervision.
10. Understand all aspects of the functionality of Access Express/EZ-CAP, Crystal Reports with respect to quality management appeals.
11. Complete and assigned tasks accurately and within specified time limits.
12. Maintain smooth working relations with co-workers and supervisors. Be a “Team Player”
13. Excellent verbal and written skills in order to clearly convey complex information, or ideas to Medical Director and other internal and external customers (i.e. health plan representatives).
14. Ability to speak to individuals using appropriate grammar and vocabulary to obtain information, explain applicable policy and procedure, when necessary.
15. Skill in writing grammatically correct letters and in proper business format.
16. Skill in organizing material and information in a systematic and accurate way to minimize errors.
17. Ability to maintain confidentiality with sensitive information.
18. Ability to adhere to Regal Medical Group policies and procedures.
19. When identifies a problem, informs supervisor in a timely manner so that the problem can be corrected.
20. Prepares and maintains records and files which are neat, organized, thorough, and readily accessed.
21. Completes assignments within specified timelines.
22. Filling, faxing, copying, purging of files.
23. Ability to work business hours with flexibility in order to meet deadlines.
24. Other duties as directed by management.

The pay range for this position at commencement of employment is expected to be between $23 - $25 per hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.

Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Qualifications

Education and/or Experience:

• Minimum High School graduate
• Minimum one (2) year of Quality Improvement experience.
• Three to five (3-5) years of managed healthcare experience preferred.
• Computer literate in work, excel.