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EyeMed - Sr Analyst- Medical Management (Quality Assurance)

Date:  Sep 23, 2022
Brand:  EyeMed Vision Care
Location: 

Mason, OH, US, 45040

Requisition ID: 733122 
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 Sr Analyst serves as the main resource responsible for provider quality initiatives as it relates to Utilization Management, Grievance and Appeals, Provider Quality programs and operations. This role will collaborate with the RN Nurse reviewers, Peer Clinical reviewers, G&A Specialists, Provider Analysts and/or Medical Directors to provide operational support with clinical and quality processes.  This role will also contribute to new client implementation and procedures using critical thinking approach and applying technology and business process to achieve quality results. 

 

MAJOR DUTIES AND RESPONSIBILITIES

  • Gathers clinical, claims, appeal and grievance information regarding cases for root cause analysis and solution proposal
  • Develop and maintain audit tools based on regulatory compliance with CMS requirements.
  • Maintain data and develops processes and procedures to ensure data integrity
  • Contribute to the development of program KPI’s and scorecards to ensure overall effectiveness of the provider quality programs.
  • Drive data collection and required data needed to ensure quality KPI reports.
  • Execute, optimize and drive efficiencies with inbound and outbound correspondence from providers and members (i.e. letter management) while maintaining CMS standards
  • Perform clinical reviews for vision services while following the established clinical criteria for the selected service and line of business (i.e. Medicaid, Medicare).
  • Preparation of files/charts to support regulatory and customer audits.
  • Manage appeals for services that are denied, interpreting appropriateness of case and accurate claim payment as part of appeal process.
  • Significant contributor to system migration efforts to new provider platforms and acts as UAT resource on new system enhancements to ensure business processes are achieved on new platforms.
  • Develop methodologies and functionalities to automate and streamline processes within Provider Relations department.
  • Read and interpret regulatory requirements to determine how to operationalize within the existing team policies and procedures.
  • Audit and review of policies and procedures, letters, and letter attachments against legislative requirements and business practices.
  • Assist in identifying areas of training opportunity and create training materials.
  • Design, develop and distribute new reporting and data analyses based on need
  • Drive assigned projects through completion.

 

BASIC QUALIFICATIONS

  • Bachelor’s Degree or equivalent work experience
  • At least +3 years of experience in Operations / Process type role
  • Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills
  • Advanced knowledge of Microsoft Office (Access, Excel, PowerPoint, Word)
  • Ability to work independently under general instructions and with a team
  • Knowledge of and experience with Medicaid and Medicare regulations
  • Strong organization and multi-tasking skills
  • Demonstrated ability to meet deadlines with high sense of urgency
  • Flexible working hours with ability to be onsite on limited basis. 

 

PREFERRED QUALIFICATIONS 

  • 2+ years data informatics experience in managed care, health insurance, or opthamalogy setting
  • Experience with medical terminology
  • Knowledge of utilization review process and prior authorization process in a managed health care industry
  • Experience with audit tools and scorecards measuring quality programs
  • Participation in URAC/NCQA accreditation activities

Upon request and consistent with applicable laws, Luxottica 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). 

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 receive preference in accordance with Tribal Law.


Nearest Major Market: Cincinnati

Job Segment: Medicaid, Medicare, Medical, Manager, Healthcare, Management

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