Quality Management Coordinator I
Description
Job Title: Quality Management Coordinator I
Department: Health Services – DO & Quality Management
About the Role:
We are currently seeking a highly motivated Quality Management (QM) Coordinator. This role will report to the QM Supervisor. The QM Coordinator will help facilitate the member grievance and appeal process by investigation, documentation and preparation of case files to meet all regulatory requirements. Functions will also include support to other related areas of QM.
What You’ll Do:
Appeals & Grievance:
- Investigation/Resolution of Appeals & Grievances for Assigned Health Plans
- Gather all pertinent/relevant information regarding the grievance/appeal
- Compose written correspondence to health plans
- Process and submit approved authorization for overturn denials
- Prepare case files for Medical Director and MD UM Reviewer review
- Handle inbound calls related to grievances/appeals
- Assist in Member Grievance/Appeal Withdrawal Process when appropriate
- File correspondence received daily and maintain data in the EZ-CAP/AYCE case module
QM Compliance:
- Resolves Expedited grievances/appeals within 24 hours for all product lines
- Resolves Routine Quality of Care- respond within 5 days for all product lines
- Resolves Routine Quality of Service-respond within 5 days for all product lines
- Document all grievance/appeals in an accurate and timely upon receipt
- Submit authorization for overturns to Health Plans within 24 hours for all product lines
Quality Management
- Perform ATC surveys regarding access for PCP/SPC providers
- Request medical records for PQI member grievance cases
- Perform other duties, projects and actions as assigned to support the QM department
Qualifications:
- High School Graduate or equivalent
- A minimum of 1-2 years of experience in a managed care environment (preferably IPA or MSO)
- Current knowledge of Managed Care UM procedures
- Knowledge of medical terminology, RVS, CPT, HPCS, ICD-10 codes
- Proficient with Microsoft applications and EZCAP
You're great for this role if you have:
- Experience in a doctor’s office or clinical setting
- Strong organizational skills
- Strong verbal and written communication
- Ability to multitask and problem solve in a fast-paced work environment
Who We Are:
Astrana Health (NASDAQ: AMEH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient.
Our platform currently empowers over 10,000 physicians to provide care for ~1 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.
Our Values:
- Put Patients First
- Empower Entrepreneurial Provider and Care Teams
- Operate with Integrity & Excellence
- Be Innovative
- Work As One Team
Environmental Job Requirements and Working Conditions:
- This position is remotely based in the U.S.
- The total compensation target hourly pay range for this role is: $20-23. The range represents our national target range for this role.
Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at [email protected] to request an accommodation.
Additional Information:
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.