Quality Specialist - Auditor (Disability Claims / FMLA)

Quality Case Management Specialist

Reporting to the Quality and Clinical Manager, you will act as a leader and influencer of quality case management. You will support case manager development and compliance with TELUS Health's best practices through direct coaching, auditing, training, complex file reviews, and other quality responsibilities. The goal of the quality program and the direct role of the Specialist is to collaborate with our service delivery teams acting as an expert resource in quality case management.

Knowledge of FMLA, state leave laws, Short Term Disability (STD) plans, ADA, PWFA and other leave laws as required.

Coaching and mentoring of the Service delivery teams to ensure consistency in communication, positive client experience, and application of the best practice fundamentals of case management.

The Specialist completes new hire and regular audits reviews.

Through the completion of regular audits, the Specialist ensures the case managers are manage claims consistent with regulatory requirements, Service Level Agreements, process flow(s) and TELUS Health's best practices.

Identify opportunities for efficiency and effectiveness of case management service delivery.

Working with the Service Delivery Management team to recommend solutions for identified issues and assist with the implementation of noted solutions.

Ability to identify both positive and negative trends and recommend solutions to address such patterns.

Collaborate with the service delivery manager and case managers to create an environment that fosters development of a mutual vision / strategy and empowerment of teams.

Assist with training initiatives as needed.

Assist with Case Management functions as needed.

Liaise with Service Delivery to ensure file completeness prior to completing assigned appeals. Preparation of file summaries and gap analysis for claims with legal involvement. The Advisor works closely with the legal team, Service Delivery leadership and Quality and Clinical Manager to ensure appropriate decisions and makes recommendations to eliminate identified risk.

Assisting with consultations for Service Delivery and / or Legal Counsel on a variety of complex cases. Providing subject matter expertise on medical case management to the Disability Management product team as needed

Qualifications :

The ideal candidate has a minimum of 5 years of Disability Case Management experience.

Preferred : requires a Post-secondary degree / diploma in any of the following fields : Health Sciences, Medical, business, counseling, human services, human resources or health and wellness Strong business acumen, psych Mental health claims management experience

5 years minimum experience in lieu of a Bachelors, in Disability Management (minimum required)

Coaching and mentoring experience an asset.

Previous auditing experience an asset

The incumbent has strong coaching, communication, interpersonal and leadership skills

Requirements :

Bilingualism (Spanish) an asset

Excellent written and oral communication skills

Excellent time management skills.

Expert knowledge of the principles in Disability Case Management

Has advanced knowledge of FMLA, state leave laws, Short Term Disability (STD) plans, ADA, PWFA and other leave laws as required.