Operational Excellence Specialist

JOB PURPOSE:

Under the direction of the A&G Manager/Senior Shared Services Manager, the Operational Excellence Specialist supports accuracy, consistency, timeliness, and continuous improvement of Shared Services operations within the PACE program. The Specialist conducts quality reviews of operational cases, documentation, and participant correspondence; delivers staff training; and helps translate review findings into practical process improvements. Working with Shared Services leadership, Quality, Compliance, and Interdisciplinary Team, among others, this role promotes participant-centered service, complete documentation, and adherence to approved procedures and applicable requirements.

JOB RESPONSIBILITIES:

Quality Assurance and Case Reviews

• Conduct routine, targeted, and risk-based reviews of transactions, work queues, case records, and supporting documentation using approved tools and sampling methods.
• Review assigned cases from intake through closure for accuracy, completeness, timeliness, correct routing, documented follow-up, and adherence to approved workflows and applicable PACE requirements.
• Document findings objectively, distinguish isolated errors from recurring process issues, and coordinate corrections with responsible case owners.
• Maintain review logs, track remediation, and perform follow-up reviews to confirm effective corrections.
• Participate in calibration sessions to support consistent review standards.

Participant Correspondence and Risk Escalation(applicable to SDR / Appeals and Grievances Unit only) 

• Review participant and authorized representative letters for SDRs, Appeals and Grievances before release for accurate recipient information, dates, case details, approved templates, readability, and consistency with documented decisions.
• Verify required notice elements, applicable timeframes, language and accessibility needs, and delivery documentation using Compliance, NYDOH and CMS approved criteria.
• Promptly escalate participant-rights concerns, overdue actions, privacy issues, and significant quality risks.
• Refer clinical judgments, service determinations, and legal or regulatory interpretations to authorized personnel; do not independently change clinical decisions or approved notice language. 

Training and Knowledge Management

• Develop and deliver onboarding, refresher, and process-change training; provide process-focused coaching on documentation, correspondence, workflows, and system use.
• Develop training decks and keep them updated with the operational changes.
• Maintain approved procedures, job aids, checklists, letter-review guides, and training materials with process owners, including version control and distribution.
• Use identified cases and recurring findings in practical learning activities.
• Track attendance and completion and assess effectiveness through knowledge checks and post-training quality trends. 

Continuous Improvement and Reporting

Analyze quality findings, repeat errors, rework, turnaround times, and bottlenecks; support root-cause analysis, process mapping, corrective action plans, and small-scale improvement tests.

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

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

Protect confidential information and follow privacy, security, and records-management policies.

Schedule: 8:30AM – 5:30PM

Weekly Hours: 40 

QUALIFICATIONS: 

Education: Associate's Degree in business, health care, or related field, or equivalent. 

Experience:

• Minimum of one (1) year of experience working with a frail or elderly population or, if the individual has less than one (1) year of experience but meets all other requirements, must receive appropriate training from the PACE organization or related industry on working with a frail or elderly population upon hiring.
• Required experience in healthcare, Medicare & Medicaid, CMS guidelines, customer experience, quality review and appeals and grievances.
• Experience using electronic medical records, case tracking systems, customer relationship management systems, or similar documentation platforms.
• Excellent written and verbal communication skills (grammar, spelling, and punctuation).
• Ability to thrive in a fast-paced environment and meet assigned deadlines.
• Excellent organizational skills, accuracy, and attention to detail.
• Demonstrated ability to manage multiple projects and be flexible.
• Ability to operate both independently and collaboratively as required.
• Proficiency in Microsoft Office suite, including Word, Excel, and Outlook.
• Fluent in English language; bilingual preferred. 

Physical Requirements

Individuals must be able to sustain certain physical requirements essential to the job.

This includes, but is not limited to:

• Standing – Duration of up to 6 hours a day.
• Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.
• Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and other items used in the scope of the job using OSHA guidelines, etc.
• Bending/Squatting – Have to be able to safely bend or squat to perform the essential functions under the scope of the job.
• Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas.
• Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools to complete essential job functions (ie. typing, use of supplies, equipment, etc.)
• Sight/Visual Requirements – Must be able to visually read documentation, papers, orders, signs, etc., and type/write documentation, etc. with accuracy.
• Audio Hearing and Motor Skills (language) Requirements – Must be able to listen attentively and document information from patients, community members, co-workers, clients, providers, etc., and intake information through audio processing with accuracy. In addition, they must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.
• Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.

Disclaimer: Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company.

We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.

Salary Range (Min-Max):

Every application is reviewed by our recruitment team. We do not use AI to make hiring decisions or automatically reject applicants. All employment decisions are based on job-related qualifications and applicable employment laws.

CenterLight Healthcare System currently hires employees in states where we are registered to do business. At this time we are able to consider candidates residing in the following states:

• Alabama
• California
• Colorado
• Connecticut
• Florida
• Georgia
• Illinois
• Louisiana
• Maryland
• Massachusetts
• New Jersey
• North Carolina
• Ohio
• Oklahoma
• Oregon
• Pennsylvania
• Puerto Rico
• South Carolina
• Tennessee
• Texas
• Utah
• Virginia
• Wisconsin