Operational Excellence Specialist

This is a fully remote position, open to applicants in Alabama, +20 more states.

📋 Description

• Perform routine, targeted, and risk-based evaluations of transactions, work queues, case records, and accompanying documentation.

• Assess assigned cases from initiation to closure for accuracy, completeness, timeliness, routing, follow-up, adherence to workflow, and applicable PACE requirements.

• Record findings, differentiate between isolated errors and recurring process issues, coordinate necessary corrections, maintain review logs, track remediation efforts, and carry out follow-up evaluations.

• Engage in calibration sessions to uphold consistent review standards.

• Review participant and authorized representative correspondence for SDRs, Appeals, and Grievances prior to release when applicable.

• Confirm notice elements, timelines, language and accessibility requirements, and delivery documentation utilizing Compliance, NYDOH, and CMS-approved standards.

• Elevate concerns regarding participant rights, overdue actions, privacy issues, and significant quality risks.

• Refer clinical assessments, service determinations, and legal or regulatory interpretations to designated personnel.

• Create and deliver onboarding, refresher, and process-change training, along with process-focused coaching.

• Develop and refresh training materials.

• Maintain approved procedures, job aids, checklists, letter-review guides, and training resources with input from process owners, ensuring version control and distribution.

• Utilize identified cases and recurring findings in educational activities; monitor attendance and completion and evaluate training effectiveness.

• Analyze quality findings, repeated errors, rework, turnaround times, and bottlenecks; assist in root-cause analysis, process mapping, corrective action plans, and improvement tests.

• Report review volumes, error categories, recurring themes, remediation status, and improvement outcomes to management.

• Support audits and monitoring by organizing review evidence, training records, procedures, and corrective action documentation.

• Safeguard confidential information while adhering to privacy, security, and records management policies.

⛳️ Requirements

• Associate's Degree in business, healthcare, or a related field, or equivalent experience.

• At least one (1) year of experience working with a frail or elderly population, or appropriate PACE organization or related industry training upon hiring if under one year and all other qualifications are satisfied.

• Experience in healthcare, Medicare & Medicaid, CMS guidelines, customer experience, quality review, and appeals and grievances.

• Familiarity with electronic medical records, case tracking systems, customer relationship management systems, or comparable documentation platforms.

• Exceptional written and verbal communication skills, including grammar, spelling, and punctuation.

• Capability to excel in a fast-paced environment and meet designated deadlines.

• Strong organizational skills, accuracy, and meticulous attention to detail.

• Proven ability to manage multiple projects and demonstrate flexibility.

• Ability to work independently as well as collaboratively.

• Proficiency in Microsoft Office suite, including Word, Excel, and Outlook.

• Fluent in English; bilingual candidates preferred.

• Ability to satisfy specified physical requirements, including standing, sitting, lifting/pushing/pulling up to 50 pounds, bending/squatting, navigating stairs and walking, performing fine motor skills, visual reading and documentation, attentive listening, clear speech, and cognitive ability.

🏝️ Benefits

• Work from the comfort of your own home.

• Reasonable accommodations available for individuals with disabilities.

• Commitment to affirmative action and equal opportunity employment.