Operational Quality Services Specialist, Associate

Blue Shield of California•Redding, CA

3d•Hybrid

About The Position

The Operational Quality Services team conducts audits, documents quality issues and performance measures and conduct reviews of policies and procedures to ensure alignment with service level requirements. The Operational Quality Services Auditor will report to the Operational Quality Services Supervisor. In this role you will be responsible for performing production and quality control audits to measure performance. Assures adherence to established specifications and quality standards. Conducts comprehensive quality review to identify performance deficiencies. May use quality analysis tools to analyze trends, root causes and identify systemic corrective action opportunities. Creates management reporting for review and follow up. Other duties as assigned. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Requirements

Bachelor’s degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree
Knowledge in health care compliance, legislative or legal services, healthcare, privacy, audit or investigative services preferred
Practical knowledge of production and quality control audits typically obtained through advanced education combined with experience
Knowledge and experience with claims processing preferred

Responsibilities

Responsible for performing basic production and quality control audits for internal claims and external Medicare, HMO or PPO providers.
Conducts comprehensive quality reviews of claims, enrollment, or customer service using a standard audit model.
Responsible for identifying revision of policies and procedures to comply with regulatory changes and for training internal staff or delegated providers.
Draft communications to operations when necessary
Responsible for reporting, maintaining quality and corrective actions.
May represent BSC with internal/external entities.
May review lower-level employee work
Communicate audit issues immediately, and provide potential solutions
May participate in corrective/preventative action planning.
Interacts with operation representatives to influence outcomes.
May participate in the development of claims training, projects and taskforces as assigned.