* Support QI Nurses, QI Supervisor, QI Manager, QI Director and others within the QI Department.
* Ensure appropriate resolution of member appeals, grievances and QIO requests in a timely and appropriate manner.
* Identify non-compliance with state, federal and Health Plan standards when investigating appeals and grievances and intervene as appropriate.
* Track and trend incidents of service and clinical quality of care issues and identify opportunities for improvement.
* 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 and present case summaries for medical review which would include for both appeals and grievances but not limited to: requesting the appropriate medical records, request written responses, creating the appeal packet and presenting it to the nurse to review, responding to all health plan inquires in conjunction with the QI nurse.
* Generate meaningful and accurate reports, queries, graphs, and presentations.
* 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 HEDIS, medical records audit 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.
* 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 and Power Point
* Experience applying evidence-based criteria (i.e.: MCG, Interqual, Hayes); Health plan medical policy / clinical coverage guidelines, CMS (Centers for Medicare and Medicaid Services) coverage policies and with ICE (Industry Collaborative Effort) denial language.
* Knowledgeable of medical terminology
* Experience checking eligibility benefits and referrals within an electronic system required.
Internal Number: MEM003511
About MemorialCare Health System
Let us introduce ourselves. We're MemorialCare, a nonprofit health system that includes four hospitals, two medical groups, imaging centers, surgical centers and much more. As one of the leading health systems in Orange County and Los Angeles County, we're confident that no matter what your needs are, we have the teams, tools and know-how to support you every step of the way.