14 days old

Quality Assurance Associate _ Mason, OH

Kelly Services
Mason, OH 45040
**Medical Claims/Grievances Quality Assurance Associate _ Mason, OH**

Kelly Services is currently seeking a Medical Claims/Grievances Quality Assurance Associate for one of our top clients in Mason, OH.

Hours: 8:00am to 5:00pm / Remote till pandemic lifted

Length of assignment: 13 weeks (possible extension)

Pay: $16/hr - $18/hr


Responsible for leading the resolution of member or provider complaints and grievances relative to quality of care, access to care, and benefit determination.


+ Member and Providers Complaints/Grievances. Serves as a liaison between provider and member or members representative with regard to resolution of Member complaints.

+ Conducts research and secures required information, including requesting member records, claims analysis, transaction/event documentation.

+ Prioritizes and analyzes member and provider issues and seeks EyeMeds Medical Director involvement as needed.

+ Interact with other departments including Member Services, Claim, and Legal to resolve member and provider complaints and grievances.

+ Logs, tracks, and processes complaints and grievances forwarded to the Quality Assurance. Department.

+ Reports on KPIs for department and, as required, for Clients.

+ Maintains all documentation associated with the processing and resolution of complaints and grievances to comply with regulatory and client standards.

+ Maintain accurate, complete complaint/grievance records in the electronic database.

+ Coordinates Complaint Sub Committee meetings include preparing the agenda, notifying participants, and maintaining minutes of the meeting.

+ Meets established quality and productivity standards in all areas of complaints and grievances, including client performance guarantees and any federal and/or state regulations as they relate to complaints and grievances.

+ Composes final letters that appropriately reflect the Complaint Sub Committee decision. Interacts with members and providers to ensure implementation of Committees decision.

+ Offers appropriate next steps to all unsatisfied members and assist them with proper filing.

+ Based on case analysis and historical resolution precedents, establishes and communicates recommended dispute resolution.

+ Develops formal request and response letters and written summaries of cases including the facts of the case, resolution, and directions re. Provider education/actions.

+ Acts as a member and provider telephone contact for complaint grievance.

+ Handles escalated calls from provider and/or members in a professional and courteous manner.

+ Constructively challenge existing processes and search for opportunities to improve processes. Special Exception Processing: Serve as a liaison between Provider Relations and Eyemed claims department for handling all medically necessary claims (i.e. medically necessary contact lenses, low vision, medical).

+ Follow up with providers to obtain missing information for clean claim to ensure approval/denial from Eyemed Medical Director.

+ Compose letter to inform provider of approval/denial of medically necessary claim.

+ Log, track and report on all medically necessary claims.

+ Meets established productivity and quality standards.


+ Demonstrates excellent oral and written communication skills.

+ Demonstrates strong problem-solving skills.

+ Demonstrates strong organizational and follow-up skills and ability to multi-task.

+ Working knowledge of private doctor community, managed vision care and optical terminology/process.

+ Working knowledge of CPT Codes.

+ Proficient with both Word and Excel.

+ Ability to work effectively on an individual basis or part of a team.

+ High level of professionalism and ability to deal with sensitive information

+ Strong oral and written communication skills

+ Ability to work well under pressure and multi-task

+ High sense of urgency and ability to manage to strict deadlines

+ Demonstrated resourcefulness in resolving problems

+ Demonstrated ability to learn new technology systems and query reporting

+ **Minimum of 2 years practical work experience in claims, service or health services environment.** Preferred knowledge of claims processing or medical/vision benefits and product experience

+ One-year experience in healthcare related appeals/grievances, preferred.

+ High School Diploma required. Associates or Bachelors degree preferred.

Important information: This position is recruited for by a remote Kelly office, not your local Kelly branch. Applicants must be legally permitted to work in the United States. Email for questions about the position but please apply online to be considered for the position.

Why Kelly?

+ As a Kelly Services employee, you will have access to numerous perks, including:

+ Exposure to a variety of career opportunities as a result of our expansive network of client companies

+ Career guides, information and tools to help you successfully position yourself throughout every stage of your career

+ Access to more than 3,000 online training courses through our Kelly Learning Center

+ Weekly pay and service bonus plans

+ Group-rate insurance options available immediately upon hire*

Apply Today!

*Available for purchase and administered by a designated third-party vendor

**Why Kelly** **** **?**

As a worker today, its up to you to take charge of your career and look for opportunities to learn, grow, and achieve your potential. Helping you find whats next is what were all about. We know whats going on in the evolving world of workjust ask the 440,000 people we employ each year. Connecting with us means getting the support, guidance, and opportunities needed to take your career where you may have never imagined.

**About Kelly** ****

At Kelly, were always thinking about whats next and advising job seekers on new ways of working to reach their full potential. In fact, were a leading advocate for temporary/non-traditional workstyles, because we believe they allow flexibility and tremendous growth opportunities that enable a better way to work and live. Connecting great people with great companies is what we do best, and our employment opportunities span a wide variety of workstyles, skill levels, and industries around the world.

Kelly is an equal opportunity employer committed to employing a diverse workforce and providing accommodations for people with disabilities in all parts of the hiring process as required under its Employment Accommodation Policy. Kelly will work with applicants to meet accommodation needs that are made known to Kelly in advance.
Posted: 2020-11-11 Expires: 2020-12-12

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Quality Assurance Associate _ Mason, OH

Kelly Services
Mason, OH 45040

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