Position
Quality Improvement Specialist
Description
Under minimal supervision and in a professional manner, the Quality Improvement Specialist performs all job duties to the highest level of customer service and assistance to both internal and external customers of Memorial Care Medical Foundation. This position requires exceptional interpersonal communication, customer service, and organizational skills required. The quality improvement specialist is required to meet all managed care delegation requirements for this position to ensure compliance with meeting all turnaround times for preservice appeals and denial letters.

• Support QI Nurses, QI Supervisor, QI Manager, QI Director, and others within the QI Department.
• Meet all regulatory compliance standards for Pre-service member denial letters consistently and ensuring the following processes are met; ensure the correct application of service denial language, utilizing the most current Industry Collaboration Effort (ICE) and CMS templates and regulations.
• Collaborate with QI nurses to prepare appeals and grievances but not limited to: responding to all health plan inquires in conjunction with the QI nurse.
• Support the Quality Improvement Program, including proper management of grievances, appeals, internal referrals, member pre-service denial letters, focused quality, and service audits. In addition, the Quality Improvement Specialist supports other QI activities related to health plan audits, medical record audits and access audits. The QI Specialist serves as a liaison for internal and external customers in matters affecting members, providers and other customers.
• Maintain department compliance with all federal, state, local laws, regulations, accreditation, and other related requirements along with all organizational policies and procedures
• Other duties as assigned.

Requirements

• A minimum of 2-5 year experience in Managed Care
• Strong interpersonal communication, customer service, and organizational skills required
• Advanced computer proficiency in Microsoft Office : Outlook, Word, Excel, Power Point, and Adobe
• Knowledgeable of medical terminology
• Experience checking eligibility benefits and referrals within an electronic system required.

Additional information

• Mostly remote but must be able to go onsite for meetings.

INDH
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