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Operations Specialist
Ref No.: 18-03566
Location: Mason, Ohio
Start Date: 05/29/2018
 
Description/Comment: JGENERAL FUNCTION

The QA Ops Specialist leads the resolution of member and provider complaints and appeals related to quality of care, access to care and benefit determination.


MAJOR DUTIES AND RESPONSIBILITIES

• Work collaboratively with other departments including customer care, claims, and legal to investigate and resolve member complaints and appeals.
• Prioritizes and analyzes member/provider issues and seek EyeMed's Medical Director's involvement as needed.
• Develops formal request and response letters and written summaries of cases including the facts of the case, resolution, and directions regarding provider education or actions.
• Maintains complete and accurate complaint and appeal records in the electronic database.
• Meets established quality and productivity standards in all areas of complaints and appeals, including client performance guarantees and all applicable state and federal regulations.
• Provides monthly, quarterly and annual reporting to QA committee and clients regarding complaints and appeals to ensure compliance with performance guarantees.
• Coordinates complaints and appeals sub committee meetings.
• Participates in ongoing analysis of quality data to seek out root cause drivers of opportunities to improve overall department quality.
• Partners with management, supervisors and team leaders to provide data and feedback regarding the outcome of the department, team and quality observations.
• Participates on cross functional teams to address and resolve identified member, provider, or client satisfaction issues.
• Constructively challenges existing processes and search for opportunities to improve processes.


BASIC QUALIFICATIONS

• High School Diploma/GED
• 2+ years claims processing or vision benefits and product experience
• Strong oral and written communication skills
• Ability to work well under pressure and multi-task
• Demonstrated resourcefulness in resolving problems
• MicroSoft Office


PREFERRED QUALIFICATIONS

• Bachelor's degree in Business related disciplines
• Working knowledge of interface systems including AS400, Cura, Metastorm, Exclaim and EyeNet. Moderate working knowledge of software applications and query reporting.

Location Mason OH.
   
Hours: 8:00am to 5:00pm Location: CINCINNATI SERVICE CENTER 4000 LUXOTTICA PL MASON OH 45040
Brand EyeMed
Brand - Description EyeMed