Complaints Quality Specialist | Alabaster, AL

health care providers and increase a health plan's ability to connect members to quality care. With the industry's largest network of care navigators and technology powered by more than six million backssments and more than 20 years of data, Lucet is the only solution proven to successfully identify and connect people across the entire acuity spectrum with the right care in less than five days on average, and often as little as one day.

Our members, providers and partners fully entrust us to deliver outstanding quality care through coordinated behavioral health services, employee assistance programs, organizational consulting, student well-being programs and more. When you join Lucet,

you become a valued member of our team, serving more than 15 million people across the U. S. Our employees have a passion for helping others - and it shows. From entry-level employees to senior leaders, we are inspired by our members, putting them first in everything we do.

From day one, you'll see firsthand the impact you have on our members, knowing you can make a true difference in their lives. Job Summary The Spec, Complaints Quality is responsible for the processing of quality of care complaints, grievances and incidents. Duties include all aspects of clinical quality of care complaint and incident investigations including documentation, interviews, obtaining responses from providers

or facilities, reviewing medical records, staffing findings with the medical director, and resolution processes.

This position requires knowledge of standards of care, identification of trends and include audit activity of medical records. The CQS is responsible for clearly written reports, and monitoring compliance. Essential Functions Appropriate processing and documentation of complaints, grievances, and incidents. Manage complaint investigations and resolution processes professionally, confidentially, collaboratively and timely. Review patient medical records and utilize clinical and regulatory knowledge and skills to investigate complaints, grievances, and incidents.

Communicates detailed account of quality of care issues to management as appropriate. Manage projects as assigned: develop, design, analyze, direct and present the projects to various customers. Identify opportunities for improvement and take action to address the identified gaps. Support and guide complaints and incidents with management staff and line staff in other departments to achieve timely resolution. Participate in multidisciplinary regional workgroups, teams, and committee meetings for projects, reporting and in an advisory role. Perform data collection and analyses used for complaints and incident reports and audits; departmental and improvement teams; and accreditation.

Use statistical analyses as appropriate. Prepare and present reports for the purpose of the customer reporting; internal meetings; external auditors; external meetings with providers; senior executives; Board of Directors; external customers and employers, etc. Assist with accreditation preparation and development of reports/deliverables. Coordinate accreditation projects with other departments and regional services centers through consultation and facilitating workgroups, teams, and departments implementing and monitoring accreditation standards.

Participate in regional performance improvement initiatives as a team member, facilitator, or subject matter expert. Use performance improvement methodology and basic tools to facilitate small to moderately sized change initiatives. Adheres to Lucet Health Mission Statement, Core Values, Code of Business Conduct and Compliance Program Complies with all Federal and applicable State laws and Lucet policies regarding privacy, confidentiality and security of health information and other designated information Job Qualifications Required Unencumbered license to practice independently in a behavioral health related field or a BSN/RN with a minimum of 3 years post licensure behavioral health experience with facility-based and/or outpatient behavioral health or chemical dependency treatment.

Minimum of 1 year working with quality management principles, study design, data analysis, and report preparation 1 -3 years previous experience in medical record review, interpreting medical and behavioral cases with a cognitive understanding of evidence- based standards and medical practice. Strong written communication skills including routine ability to compose correspondence, memos, and reports, with text tables and graphics as required.

Intermediate skills with Microsoft Office (Word, Excel, Power Point and Outlook) and Visio Critical thinking and analytical skills; able to decipher best practice research with statistical discrimination, design audits and surveys. Preferred Managed Care experience highly preferred Lean Six Sigma certified (Green belt or higher) or CPHQ certified Experience with complaints, grievances, risk management or auditing. 2 or more years of experience in accreditation, regulatory compliance or risk management.

Key Attributes Empathy Critical thinking Flexibility Ability to multi-task Highly organized and detail-oriented Adaptable to various software programs Actively participate in and positively contribute to team processes and lead team activities Problem Solving Job Posted by Applicant Pro