Qa Ops Specialist (Provider Relations)

Requisition ID: 833503 
Position:Full-Time
Total Rewards: Benefits/Incentive Information

 

There’s more to EyeMed than meets the eye. EyeMed is the fastest growing managed vision benefits company in the country with consistent double-digit membership growth! Through our commitment to innovation, we’re reimagining the way employers and their employees think about vision care. We want them to see life to the fullest and experience more of what’s best, not more of the same.  And if what’s best hasn’t been done yet, it’s our exceptional and passionate employees driving this change. But, our passion for vision isn’t just about vision insurance benefits. Our employees are proud to support and participate in life-altering global and local missions through our partnership with OneSight, a leading not-for-profit organization with a 100% focus on eradicating the world’s vision crisis.

 

Your family says a lot about who you are. EyeMed is a key member of the Luxottica family of companies, global leaders in the design, manufacture and distribution of fashion, luxury and sports eyewear.  In North America, Luxottica is the home to global brands Ray-Ban, Oakley and many top fashion house brands.  Our leading retail brands include LensCrafters, Sunglass Hut, Pearle Vision, and Target Optical.

 

If you’re passionate about driving innovation and change and interested in a career in the optical and insurance industry, EyeMed wants to start the conversation and help provide you a growth-focused opportunity with America’s fastest growing vision benefits company.

GENERAL FUNCTION

The Quality Assurance Specialist leads the resolution of member and provider complaints and appeals related to quality of care, access to care, and benefit determination.

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 Luxottica Ethics Compliance Hotline at 1-888-887-3348 (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. 

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