Quality Assurance Specialist

Location: Orange, California US

Notice

This position is no longer open.

Job Number: 4950

Workplace Type: Office Full-Time

Position Title: Quality Assurance Specialist

External Description:

Quality Assurance Specialist

Summary

Responsible for monitoring the day to day data submitted to CMS. Review of weekly TRR, Monthly TRR and reconciliations between CMS and AHP internal system. Will report the outcome to the department heads to ensure compliance as required by CMS. Assist internal staff, members and providers as necessary. Monitor calls eligibility calls and responsible for generating department reports.

Essential Duties and Responsibilities

Essential duties and responsibilities include, but are not limited to:

  1. Review on a daily basis the TRR. Follows up with the staff on any pending enrollments or rejections. Ensure the 4RX on every member is submitted with in 48 hours.
  2. Responsible in the reconciliation of the data between CMS and AHPs internal system.
  3. Ensure that all systems are in place when there are CMS software updates or changes.
  4. Collaborate with I.T. on all CMS updates.
  5. Evaluate and monitor the performance and efficiency of programs to ensure that program implementation is on target.
  6. Plan manage and monitor minor projects from concepts through implementation.
  7. Ensuring that all team members understand the scope of the project as well as what they are individually responsible for.
  1. Performs monthly mock audit to ensure all areas with in the department are compliant (OEV calls, enrollments, disenrollment, COB, LIS, LEP etc.).
  1. Monitor eligibility calls on a monthly basis.
  2. Responsible of ensuring the welcome packets are sent to members with in the allowable time frame and forwarded to vendor.  Tracking of all returned mail.
  3. Ensure that all applicable members are mailed the Educational (OEV) letter with in the required time frame.
  4. Ensure that all qualifications are met for all CSNP enrollments.
  5. Ensure all qualifying documentation is stored within internal system.
  6. Ensure all CSNP timeframes are documented and met.
  7. Acts as direct liaison for the internal and external Sales Representatives as well as other corporate staff.  Ensures that new enrollments are processed properly.  Provide any issues identified to the necessary internal department heads. As well as the Broker Agencies.
  8. Submits monthly reports to the Membership Director of completed calls, applications processed and returned, conflict reports between CMS and EZ-Member, Rejects, Denials. Disenrollment report and number of mailed packets and returned mail.
  9. Responsible and accountable for the training, and overall performance of the Membership Unit staff to ensure that all qualitative and quantitative goals and objectives are met within the department.
  10. Performs other duties as assigned.

Responsibilities

Responsibilities include training employees; planning, assigning and directing work; addressing complaints and resolving problems.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  1. Education and/or Experience:  High school diploma or general education degree (GED); or one to three months related experience and/or training; or equivalent combination of education and experience.
  2. Certificates, Licenses, Registrations:  None required.
  3. Other Qualifications: 
    1. Knowledge of MediCal and Medicare Advantage Prescription Drug Plans.
    2. Four years customer service experience.
    3. Direct sales or related experience preferably in the Managed Care industry.
    4. Bilingual (English/Spanish) required.
    5. Basic Computer Skills, 25 WPM (Microsoft Outlook, excel, word)
    6. 10-Key by Touch

 Skills and Abilities

  1. Language Skills:  Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals.  Ability to write routine reports and correspondence. 
  2. Mathematical Skills:  Ability to add and subtract two digit numbers and to multiply and divide with 10’s and 100’s.  Ability to perform these operations using units of American money and weight measurement, volume, and distance.
  3. Reasoning Skills:  Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. 
    1. Excellent communication skills, oral and written.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  1. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
  2. The employee is frequently required to walk; stand; reach with hands and arms.
  3. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.
  4. The employee must occasionally lift and/or move up to 20 pounds.
  5. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Working Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

  1. The noise level in the work environment is usually moderate.

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Quality Assurance Specialist

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].