QA Operations Specialist (Provider Relations)

Requisition ID:888707

Store #:113004 EM Payment Integrity - OH CSC

Position:Full-Time

Total Rewards:Benefits/Incentive Information

At EyeMed, we have a unique perspective on vision benefits. By listening and staying curious, we create innovative vision benefits that are a joy to use.

Our mission is to help people see life to the fullest-and our commitment goes beyond vision benefits. Our passionate employees proudly support the OneSight EssilorLuxottica Foundation, a leading not-for-profit organization with a 100% focus on eradicating the world's vision crisis.

EyeMed is part of EssilorLuxottica, a global leader in the design, manufacture and distribution of world-class vision care products, including iconic eyewear, advanced lens technology and cutting-edge digital solutions. Join our global community of over 200,000 dedicated employees around the world in driving the transformation of the eyewear and eyecare industry. Discover more by following us on LinkedIn.

GENERAL FUNCTION

MAJOR DUTIES AND RESPONSIBILITIES

• Works 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 seeks 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 member/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.
  
• Leads cross functional teams to address and resolve identified member, provider, or client satisfaction issues.
  
• Constructively challenges existing processes and searches for opportunities to improve processes.
  

BASIC QUALIFICATIONS

• High school diploma
  
• 3+ years claims processing or medical/vision benefits and product experience
  
• 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
  
• Ability to work independently
  

PREFERRED QUALIFICATIONS

• Bachelor's degree in Business related discipline
  
• Industry experience in insurance complaint and appeal resolution
  
• 2+ years claims processing or medical/vision benefits and product experience
  
• Understanding of complex benefit plans and/or ability to quickly learn and process new information
  
• Knowledge of Microsoft Access
  
• Working knowledge of interface systems including AS400, Cura, Metastorm, Exclaim and EyeNet
  

Employee pay is determined by multiple factors, including geography, experience, qualifications, skills and local minimum wage requirements. In addition, you may also be offered a competitive bonus and/or commission plan, which complements a first-class total rewards package. Benefits may include health care, retirement savings, paid time off/vacation, and various employee discounts.

Upon request and consistent with applicable laws, EssilorLuxottica will provide reasonable accommodations to individuals with disabilities who need assistance in the application and hiring process. To request a reasonable accommodation, please call the EssilorLuxottica SpeakUp Hotline at 844-303-0229 (be sure to provide your name and contact information so that we may follow up in a timely manner) or email HRCompliance@luxotticaretail.com.

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, gender, national origin, social origin, social condition, being perceived as a victim of domestic violence, sexual aggression or stalking, religion, age, disability, sexual orientation, gender identity or expression, citizenship, ancestry, veteran or military status, marital status, pregnancy (including unlawful discrimination on the basis of a legally protected pregnancy or maternity leave), genetic information or any other characteristics protected by law. Native Americans in the US receive preference in accordance with Tribal Law.