Operational Quality Services Specialist, Associate

Blue Shield of California•Long Beach, CA

1d•Remote

About The Position

The Operational Quality Services Specialist, Associate is part of the Medi-Cal Operations team, which ensures claims are processed accurately and in a timely manner. Reporting to the Medi-Cal Operations Senior Manager, this role performs routine audits for all claim types in the Medi-Cal line of business. The position conducts quality reviews, supports compliance with regulatory requirements, identifies and resolves routine issues, and helps train and guide staff and delegated providers. The role allows employees to work virtually full-time, with office attendance as business needs require.

Requirements

Bachelor’s degree, or a high school diploma/GED and four years of additional relevant experience in lieu of a degree.
Relevant experience.
At least one year of previous claims-processing experience covering all claim types.
Knowledge of DHCS guidelines.

Nice To Haves

Prior auditing experience.

Responsibilities

Perform basic production and quality-control audits for internal claims and Medi-Cal providers, where limited judgment is required.
Assure quality against in-house and/or external specifications and standards.
Conduct comprehensive quality reviews of claims, enrollment, or customer service using a standard audit model.
Identify revisions to policies and procedures needed to comply with regulatory changes, and train internal staff or delegated providers.
Initiate corrective measures and track their timely completion.
Identify and resolve routine problems independently, escalating issues to a supervisor as appropriate.
Identify root causes of errors, perform impact analysis, and communicate mitigation steps to appropriate parties.
Maintain current and comprehensive knowledge of applicable claims regulatory requirements, including AB 1455 and DHCS regulations.
Independently review and interpret standards, procedural documentation, contracts, and legal verbiage.
Provide guidance, coaching, and training to other employees within the job area.
Perform other related duties as assigned.