JOB SUMMARY: MUST HAVE HEALTH PLAN EXPERIENCE

Under the clinical direction of the Team Manager Clinical Quality & Patient Safety, the Clinical Quality Specialist is responsible for all assigned operational aspects of the Member Clinical Grievance and QI Occurrence process for Commercial, Senior and Public Plans products. Responsibilities include but are not limited to timely review and investigation of member clinical grievances and QI Occurrences. The Clinical Quality Specialist works in collaboration with various Health Plan departments, network providers, outside organizations to ensure regulatory requirements and time frames are met in processing member clinical grievances and QI Occurrences.

The Clinical Quality Specialist must possess broad understanding of all products and benefits as well as understand regulatory requirements and time frames. The Clinical Quality Specialist routinely interacts with providers and other internal and external constituents in the investigation process.

Essential job functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary. These essential functions need to be performed on a consistent and regular basis, using good judgment. The employee must have the ability to learn and apply Health Plan policies and complex and frequently changing regulatory requirements consistently and the judgment to seek out guidance as needed.

The Clinical Quality Specialist must have excellent writing skills with written work requiring minimal oversight by the Team Manager Clinical Quality & Pt Safety.

KEY RESPONSIBILITIES:

PROCESSING OF MEMBER CLINICAL GRIEVANCES:

• Review initial research on clinical grievances.
• Ensure each assigned clinical grievance is categorized per department standard.
• Correspond with the member as required (closure letters and telephone contact as appropriate).
• Correspond with the provider as required (written inquiry, closure letters and telephone contact) as defined by department standards
• Complete data entry and documentation requirements in multiple information systems including but not limited to MedHOK.
• Interact with staff at various levels within THP departments in facilitation, identification and resolution of the member's grievance.
• Generate written correspondence to members, practitioners and providers to address all aspects of the member's grievance with minimal supervision defined by department standards.
• Independently assign grievance ratings per department policy
• Responsible for meeting and complying with all regulatory and department timelines, policies and procedures.
• Responsible for ensuring Provider of Concern policy is maintained upon case closure
• Prepares Clinical Grievances per department standard for review by the Quality of Care Committee

QUALIFICATIONS:

• RN license Req MA
• BA/BS degree preferred
• Mandatory 5 years of experience
• Experience in managed care systems and operations
• Experience in Health Care Quality
• MedHok experience a plus

Position has opportunity for remote work following adequate orientation period as defined by the Senior Manager, Clinical Quality & Patient Safety

Job Types: Full-time, Contract