Job Number: 6492

Workplace Type: Office Full-Time

Position Title: Quality Assurance Specialist

External Description:

Overview of the Role

Alignment Health is seeking a Quality Assurance Specialist. As a Quality Assurance Specialist, you will be 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.

Responsibilities:

• 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.
• Responsible in the reconciliation of the data between CMS and AHPs internal system.
• Ensure that all systems are in place when there are CMS software updates or changes.
• Collaborate with I.T. on all CMS updates.
• Evaluate and monitor the performance and efficiency of programs to ensure that program implementation is on target.
• Plan manage and monitor minor projects from concepts through implementation.
• Ensuring that all team members understand the scope of the project as well as what they are individually responsible for.
• Performs monthly mock audit to ensure all areas with in the department are compliant (OEV calls, enrollments, disenrollment, COB, LIS, LEP etc.).
• Monitor eligibility calls on a monthly basis.
• 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.
• Ensure that all applicable members are mailed the Educational (OEV) letter with in the required time frame.
• Ensure that all qualifications are met for all CSNP enrollments.
• Ensure all qualifying documentation is stored within internal system.
• Ensure all CSNP timeframes are documented and met.
• 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.
• 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.
• 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.
• Training employees, planning, assigning and directing work; addressing complaints and resolving problems
• Performs other duties as assigned.

Requirements:

• 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.
• Knowledge of MediCal and Medicare Advantage Prescription Drug Plans.
• Four years customer service experience.
• Direct sales or related experience preferably in the Managed Care industry.
• Bilingual (English/Spanish) required.
• Basic Computer Skills, 25 WPM (Microsoft Outlook, excel, word)
• 10-Key by Touch

 

 

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].