Summary of Position Maintain the department's quality initiatives along with assisting in the development, implementation and maintenance of the department's quality assurance program. Identify and develop the methodologies for measuring the quality standards, track the department's quality outcomes and provide a standardized report of the results. Collaborate with various teams, conduct audits, and compile reports on quality metrics. Ensure compliance with regulations and company policies, identify trends and areas for improvement, and contribute to process improvements. Principal Accountabilities
- Perform quality audits and file reviews in a professional and confidential manner which includes consistent development, retention and application of EH benefits, contracts and departmental procedures.
- Analyze patterns and trends to identify systemic issues within the grievance and appeal process.
- Recommend changes to processes, training programs, and documentation to enhance quality and compliance.
- Maintain accurate daily logs of the files audited/prepares written reports including recommendations for improvement.
- Prepare for and participate in both internal and external audits related to grievances and appeals.
- Track and report on key metrics related to grievance and appeal handling to drive improvement efforts.
- Maintain knowledge of relevant regulations, policies, and best practices.
- Perform other activities as directed, assigned, or required.
Qualifications
- Bachelor's Degree
- 3 - 5+ years' experience in a health-related field
- Additional experience / specialized training may be considered in lieu of bachelor's degree
- Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences
- Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.)
- Experience with processing member and provider correspondence
- Working knowledge of NCQA regulations, state, and federal guidelines regarding the processing of member/provider correspondence
- Ability to analyze complex information, identify trends, and make sound decisions
- Strong written and verbal communication skills to effectively convey information and recommendations
- Ability to identify and resolve issues related to grievances and appeals
- Meticulous attention to detail to ensure accuracy and compliance in all aspects of the role
- Familiarity with relevant healthcare regulations and compliance requirements
- Prior experience in healthcare, preferably in appeals and grievances
- Ability to work effectively with cross-functional teams to address issues and implement improvements
- Proficiency in using relevant software and tools for data analysis and reporting
Additional Information
- Requisition ID: 1000003135
- Hiring Range: $56,160-$99,360
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EmblemHealth
May 02, 2026