Ohio MCO Quality Coordinator

OH - Cincinnati
8044 Montgomery Rd
Suite 250
Cincinnati, OH 45236, USA

OH - Cincinnati
8044 Montgomery Rd
Suite 250
Cincinnati, OH 45236, USA

To ensure the consistent delivery of Cor Vel’s total Ohio MCO workers’ compensation solution through the development, implementation and ongoing utilization of specific quality assurance tools and training leading to consistency and satisfied/loyal customers. Primary source of quality assurance and information for MCO’s Claims team. Supports management by handling quality assurance and escalated issues, monitoring representatives and completing quality assurance emails for team members.

Provides informational documents such as Standard Operating Procedures, Power Points, emails, and departmental newsletter to assist team members in daily tasks. Assists team members in performing daily job duties. Tracks quality assurance for individuals and the department and reports quality assurance trends.

This is a hybrid role.

ESSENTIAL FUNCTIONS & RESPONSIBILITIES:

• Conduct quality reviews/audits to ensure appropriate management of the claims and office, score the office performance, and make suggestions and follow-up to ensure office has taken action on improvement recommendations.
• Identify and participate in training and developmental needs of the claims staff including the training / re-training of all offices on existing best practices and new procedures, including usages of the Cor Vel claim system.
• Provide back‑up for incoming team calls when call volume is high and when phone reps are unavailable.
• Handle a variety of inquiries including, but not limited to claim reentry, call recording review and write‑up, and miscellaneous manual steps required for claim completion.
• Quality Assurance—gather and handle forwarded daily QA emails.
• Provide leadership and case management support to assist in daily job tasks.
• Research and handles escalated calls and e-mails in lieu of a manager.
• Communicate changes and information as necessary.
• Ability to run reports within system platform.
• Maintains knowledge of Ohio BWC rules and laws, workers’ compensation process, URAC standards, ODG, and policies and procedures.
• Provide team quality assurance for individuals to track monthly quality assurance.
• Create quality assurance monthly and yearly reports for management.
• Create and implement new‑hire and ongoing professional development training documents and testing for the Claims Management team.
• Performs claims management techniques to manage claim to optimal return to work and claim cost outcomes.
• Analyzes and processes complex or technically difficult claims by investigating and gathering information, managing claims through well‑developed action plans to an appropriate and timely resolution.
• Develops and maintains medical knowledge and understanding of clinical practices.
• Files necessary documentation with BWC and parties to the claim.
• Develops and maintains medical knowledge and understanding of clinical practices.
• Provide business‑writing training for team members.
• Publish quarterly department newsletter which presents pertinent and needed information to the team.
• Complete miscellaneous MCO projects, as needed.
• Send anniversary emails to team, aka Terrific Tenures.
• Create and run reports, as requested.
• Additional duties as assigned.

KNOWLEDGE &

SKILLS:

• Excellent professional and effective verbal and written communication skills
• Able to identify problems and get the broad view for potential and existing quality assurance cases
• Ability to analyze complex quality assurance situations, share findings and navigate toward an understandable solution
• Strong knowledge and experience in quality assurance and training programs
• Must have strong organizational skills
• Able to listen and ask pertinent questions
• Able to effectively and timely report representative quality assurance and customer issues, concerns or problems to management

EDUCATION & EXPERIENCE:

• Minimum two (2) years’ experience handling Ohio Workers’ Compensation claim adjudication
• High School diploma or GED required.
• One year administrative experience required.
• Knowledge of BWC mandatory and expected EDI transmission elements.
• Good organizational and time management…