What are the responsibilities and job description for the Quality Improvement - QOC Coordinator 195-1021 position at CommunityCare?
JOB SUMMARY:
This position is responsible for supporting the grievance and appeals activities pertaining to all written inquiries from members and providers requesting resolution through the grievance and appeals process. This includes claims and authorization research. Duties are varied and including typing, filing, photocopying, telephone follow-up, data entry, and preparation of information for presentation at committee meetings.
KEY RESPONSIBILITIES:
This position is responsible for supporting the grievance and appeals activities pertaining to all written inquiries from members and providers requesting resolution through the grievance and appeals process. This includes claims and authorization research. Duties are varied and including typing, filing, photocopying, telephone follow-up, data entry, and preparation of information for presentation at committee meetings.
KEY RESPONSIBILITIES:
- Initiate research for grievance and appeal cases including claims research, obtaining hard copies of authorizations from Medical Management/Claims and documenting basic case information for Member Services in Amisys. All cases are data entered into the grievance and appeals electronic system (GATS) for reporting and tracking purposes. This includes quality of care grievances and screening cases.
- Prepare and fax requests for medical records to provider facilities and follow-up with providers as needed. Includes follow-up with members regarding release of information, appointed representative, etc. to ensure compliance with established guidelines. Prepare appropriate letters to members and providers as indicated.
- Assist with imaging and attaching grievance and appeals documents to the electronic tracking system (GATS).
- Open, date stamp and disseminate all mail for the department. Assist with preparation of electronic case assembly for committee. Participate in Administrative Review Committee including documenting minutes.
- Organize and maintain case files in accordance with State and Federal requirements, as well as established departmental policy. Participate in case file audit process.
- Assist Manager and supervisor with other projects and duties as assigned.
- Duties and responsibilities of this role are clerical in nature and are not involved in the interpretation of clinical information or evaluations.
- Performs other duties as assigned.
- Strong oral and written communication skills.
- Successful completion of Health Care Sanctions background check.
- Organized and able to multi task.
- Ability to work effectively with personnel at all levels within the company.
- Proficient in Microsoft Office applications.
- High School Diploma or equivalency.
- Two to three years’ experience in office, managed health care, health insurance or health facilities preferred.
