MLTC-Quality Assurance Coordinator

Join Our Team as a Nurse Care Manager at RiverSpring Health Plans!

Do you have a passion for caring for older adults? If so, you've found the perfect place to advance your career! Join our compassionate and dedicated team and make a meaningful difference in the lives of our members.

RiverSpring Health Plans serves over 18,000 frail and disabled individuals, empowering them to live independently in their homes for as long as possible.

As the Quality Assurance Coordinator, you will be responsible for logging, tracking and processing appeals, grievances and incidents. The Coordinator responds to written/verbal grievances, complaints, appeals and disputes submitted by members and providers in accordance with NCQA, CMS, NY State and other regulations. Types of correspondence handled by the individual will include, but is not limited to, correspondence, payment disputes, complaints/grievances, and appeals. Work requires exercising considerable independent judgment and initiative in performing case file investigation.

Key Responsibilities:

• As the department liaison by coordinating various departments to ensure grievances/incidents are processed timely and compliance requirements are maintained.
• Identify root cause or errors and develop resolutions plans, ensures prompt resolution of case reviews and issues.
• Process all level of member and provider grievances/incidents, including assisting with escalated grievances/incidents (state/federal level).
• Receive, document, investigate, refer, resolve and coordinate grievances/incidents/appeals.
• Initiate case files for each grievance/incident/appeal and ensure compliance with organizational and regulatory requirements.
• Ensure regulatory compliance, stringent timeframe requirements and accuracy standards are met.
• Develop correspondence communicating the outcome of grievances/ non clinical incidents and appeals to enrollees and/or providers.
• Coordinate efficient functioning of day-to-day operations according to defined processes and procedures.
• Create and maintain accurate records documenting the actions and rationale for each grievance/incident or appeal decision
• Complete and coordinate department audits and quality projects as assigned.
• Performs other duties as assigned or required.

Qualifications:

• High School Diploma required
• 2 – 3 years of related work experience, must have grievance and appeals experience.
• Experience in a managed care/compliance environment preferred
• Proficiency in MS Office applications (especially word processing, and database/spreadsheet) required.
• Excellent organization skills.
• Excellent verbal and written communication skills.
• Problem solving and analytical skills.
• Outstanding attention to detail.
• Ability to speak effectively before customers or employees of organization.
• Ability to read, write and speak English.
• Bilingual a plus to be able to speak another language

Compensation:

• Annual Salary: $60,000-$65,000 
• Benefits include health insurance, retirement plans, paid time off, and professional development opportunities

• If you're ready to make a difference and support older adults in their journey to live independently, we would love to hear from you!

Equal Opportunity Employer (EOE)