Health Plan Quality Assurance & Training Specialist

Western Health Advantage•Sacramento, CA

8d•$28 - $36•Hybrid

About The Position

Western Health Advantage is seeking a Health Plan Quality Assurance & Training Specialist to support compliance, quality improvement, and staff development within our Appeals & Grievances (A&G), Utilization Management (UM), and Clinical Resources teams. In this role, you will conduct audits of clinical and non-clinical cases to ensure compliance with DMHC, NCQA, HICE, and organizational requirements. You will analyze audit results, identify trends and opportunities for improvement, maintain audit documentation and reporting, support delegation oversight activities, and assist with regulatory readiness efforts.

Requirements

Knowledge of DMHC and NCQA standards, including appeals, grievances, member rights, and health plan regulatory requirements.
Strong analytical, organizational, and communication skills.
Experience with reporting, data analysis, auditing, and quality monitoring.
Proficiency with Microsoft Office applications, including Excel, Word, and Outlook.

Nice To Haves

Associate's degree in Healthcare Administration, Business, or a related field preferred.
2–3 years of experience in Health Plan Operations, Utilization Management, Appeals & Grievances, Quality Assurance, Compliance, Managed Care, or a related healthcare environment preferred.

Responsibilities

Conduct quality audits of Appeals & Grievances and Utilization Management cases to ensure compliance with regulatory, accreditation, and organizational standards.
Review case timeliness, documentation accuracy, decision rationales, and member/provider communications.
Analyze audit findings, identify trends, and recommend process improvements to enhance quality, compliance, and operational efficiency.
Prepare audit reports, summaries, and presentations for leadership and key stakeholders.
Serve as the primary point of contact for delegation oversight activities, including tracking required deliverables and follow-up with delegated entities.
Assist with internal and external audits, corrective action plans, and regulatory readiness initiatives.
Develop, update, and maintain departmental policies, procedures, workflows, and desktop guides.
Create and deliver training programs for new and existing staff on quality standards, documentation requirements, and regulatory compliance.
Collaborate with leadership and cross-functional teams to implement process improvements and ensure consistent adherence to policies and procedures.
Monitor compliance metrics and support ongoing quality improvement initiatives.
Prepare meeting agendas, document meeting minutes, and track action items to completion.
Perform special projects and other related duties as assigned.