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Job Details

Quality Improvement Coordinator I

Requisition #: 191420
Location: Johns Hopkins Health Care, Hanover, MD 21076
Category: Clerical and Administrative Support
Work Shift: Day Shift
Work Week: Full Time (40 hours)
Weekend Work Required: Yes
Date Posted: Nov. 1, 2019

Johns Hopkins Health System employs more than 20,000 people annually. Upon joining Johns Hopkins Health System, you become part of a diverse organization dedicated to its patients, their families, and the community we serve, as well as to our employees. Career opportunities are available in academic and community hospital settings, home care services, physician practices, international affiliate locations and in the health insurance industry. If you share in our vision, mission and values and also have exceptional customer service and technical skills, we invite you to join those who are leaders and innovators in the healthcare field.

Assists in the performance of Quality Improvement related duties, including research, customer service, member outreach, member complaints and grievances, medical record review, and creation and maintenance of reports and spreadsheets. Member complaints and grievances duties include the intake, investigation, resolution, and tracking of member generated complaints and grievances. The Quality Improvement Coordinator follows JHHC service standards and collaborates with a multi-disciplinary team in order to ensure that tasks are completed within established time frames as defined in policies, procedures, regulations, and accreditation standards.

Ensures all member grievance and grievance reconsideration requests are investigated and resolved as specified by JHHC in accordance with policy, as well as accreditation and regulatory standards (NCQA, COMAR, ERISA, Medicare Managed Care Manual and/or the Tricare Operating Manual.)

Documents and tracks complaints/grievances intake, investigation, and resolution by type and line of business.

Notifies member of complaint resolution and within the required timeframes as follows:

EHP, PPMCO and USFHP

  1. Emergency Medical – within twenty-four (24) hours
  2. Non-Emergency Medical – Within five (5) days*
  3. Administrative – within thirty (30) days (Priority Partners & EHP)*
  4. Administrative – provide interim response within thirty (30) calendar days (USFHP)**
  5. Administrative – within sixty (60) calendar days written resolution (USFHP)**
  6. Priority Written Inquiries (USFHP)
  • 85% within ten (10) calendar days of receipt with written resolution;
  • 100% within thirty (30) calendar days of receipt with written resolution

Medicare Advantage:

  1. Expedited “fast” grievances – within 24 hours
  2. Standard – 30 days
  3. Extended timeframe – 44 days with member notification of the reason for the extension

Communicates with representatives from government and regulatory agencies, including the Enrollee Help Line (DHMH for PPMCO member complaints), Maryland Insurance Administration (MIA), and the Health Education and Advocacy Unit (Maryland Attorney General) in accordance with policy and procedure.

Assesses enrollee health and social risk factors. Makes appropriate referrals to care management and/or behavioral health as needed.

Educates members on plan benefits and health care needs as identified through opportunity reports or other data sources.

HEDIS and Value Based Purchasing duties include data entry, phone and/or fax contact with provider office staff, reporting, review of records to assess their inter-rater reliability, and quality assurance.

Requirements:

  • High School Diploma or GED
  • 1 year of managed care, customer service, administrative, Medicare or quality improvement experience; Experience with HEDIS, Value Based Purchasing, and/or handling complaints preferred
  • Thorough knowledge of customer service, administrative procedures and practices, managed care, and medical terminology; Knowledge of medical coding and quality improvement concepts preferred.
  • Intermediate skill in Excel, Word, and Access; Must be able to learn MC400, IDX, Catalyst, Vistar, and Business Objects
  • Excellent communication skills, both orally and written, in order to effectively communicate with all levels of staff and business-related associates
  • Excellent interpersonal skills to handle extremely sensitive and confidential information and situations specific to reporting issues and the ability to exhibit poise, tact, and diplomacy when interacting with diverse groups of people composed of employees, vendors, and other associates
  • Must be skilled in gathering and interpreting data from different sources, and checking the accuracy of reports that are produced for various users

Johns Hopkins Health System and its affiliates are Equal Opportunity/Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identity, sex, age, national origin, disability, protected veteran status, and or any other status protected by federal, state, or local law.

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