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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.


• 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.


• 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


• 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