Job Summary:
The Quality Coordinator - ESH analyzes and coordinates quality and regulatory activities related to member grievances and appeals, ensuring compliance with federal, state, contractual, and organizational requirements. Analyzes cases, evaluates compliance and operational risks, investigates concerns, and develops recommendations to support timely and accurate case resolution. Monitors quality and compliance performance, identifies trends and potential risks, and provides recommendations to support regulatory adherence and operational effectiveness. Exercises independent judgment and discretion when evaluating issues, prioritizing competing demands, determining appropriate escalation paths, and supporting compliance with HIPAA and established regulatory timeframes.
Essential Functions:
- Administer and evaluate quality and regulatory activities related to the member grievances, complaints, and appeals to ensure compliance with organizational policies, contractual obligations, and regulatory requirements; assess case circumstances, determine appropriate follow-up actions, and engage necessary internal resources to support resolution.
- Exercises judgment in prioritizing work, evaluating information, and determining appropriate actions or escalation while maintaining accurate reporting, documentation, and tracking processes.
- Ensure timely and accurate resolution of all cases while meeting established regulatory and departmental turnaround times and identify issues needing remediation.
- Serve as a liaison between members, caregivers, providers, internal departments, and external stakeholders to facilitate communication, information gathering, issue resolution, and case documentation.
- Conduct outreach to members, caregivers, providers, and other relevant parties to support grievance investigations and appeal follow-up activities.
- Evaluate cases, records, and supporting documentation to assess compliance with regulatory, contractual, and organizational requirements.
- Identify, document, and escalate potential compliance risks, quality concerns, and regulatory issues; collaborate with leadership to develop, implement, and monitor corrective action plans.
- Investigate and evaluate member complaints, and quality-of-care concerns in collaboration with Quality, Clinical, and Operational leadership
- Maintain accurate and complete documentation, databases, logs, tracking systems, and case records to ensure compliance with regulatory standards and organizational requirements.
- Monitor activities for adherence to NYSDOH regulations and other applicable requirements; interpret compliance gaps and determine appropriate follow-up actions to support timely remediation.
- Analyze and evaluate grievance, appeal, and quality data to identify trends, determine potential regulatory and operational risks, and develop recommendations for corrective actions and process improvements.
- Develop routine and ad hoc reports, dashboards, summaries, and presentations that communicate findings, trends, risks, and recommendations for operational, quality, and regulatory purposes.
- Develop member, provider, and stakeholder correspondence related to grievances and appeals, ensuring accuracy, regulatory alignment, and appropriate documentation of case findings and resolution.
- Prepare and maintain documentation required for external appeals, fair hearings, regulatory reviews, and other oversight activities.
- Perform any other job related duties as requested.
Education and Experience:
- Bachelor's degree required
- Equivalent years of relevant work experience may be accepted in lieu of required education
- Prior experience working in health care preferred
Competencies, Knowledge and Skills:
- Knowledge of Medicare, New York State Medicaid, state, federal, and accreditation requirements applicable to grievances, appeals, and incident management
- Ability to interpret and apply regulatory, contractual, and organizational requirements
- Investigative and analytical skills to assess cases, identify issues, and evaluate supporting documentation
- Ability to collect, organize, validate, and analyze information to support reporting, audits, investigations, and operational decision-making
- Demonstrated responsiveness, professionalism, and service orientation when supporting members, providers, and business partners
- Data analysis and reporting skills to identify trends and risks
- Attention to detail to maintain accuracy and completeness in documentation, reporting and regulatory activities
- Time management skills to effectively manage multiple priorities, deadlines, and case activities in a fast-paced environment
- Problem solving and critical thinking skills to evaluate options and recommend solutions
- Strong communication skills, both written and verbal
- Demonstrates proficiency in Microsoft Office applications and other systems necessary to perform job responsibilities
Licensure and Certification:
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time
- Travel is not typically required
Compensation Range:
$54,500.00 - $87,300.00
CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Salary
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
Brand=ElderServe