Operational Quality Services Specialist, Associate
About The Position
The Operational Quality Services Specialist, Associate works on the Medi-Cal Operations team, which ensures claims are processed accurately and on time. The role performs routine audits across Medi-Cal claim types, including basic production and quality-control audits of internal claims and Medi-Cal providers. It conducts comprehensive reviews of claims, enrollment, or customer service using a standard audit model, with limited judgment required for routine audits. The specialist identifies policy and procedure revisions needed to comply with regulatory changes, trains internal staff or delegated providers, initiates corrective measures, and tracks their timely completion. The role also identifies and resolves routine problems, escalates issues when appropriate, analyzes error causes and impacts, communicates mitigation steps, and maintains knowledge of applicable claims regulations, including AB 1455 and DHCS regulations. The specialist may provide guidance, coaching, and training to other employees. The position reports to the Medi-Cal Operations Senior Manager of direct manager. It allows virtual work full-time, with office attendance based on business need. The broader workplace model emphasizes purposeful in-person collaboration and flexibility; attendance expectations may change based on business needs.
Requirements
- Bachelor’s degree, or a high school diploma/GED and four years of additional relevant experience in lieu of a degree.
- Relevant experience is required.
- At least one year of previous claims-processing experience across all claim types.
- Knowledge of DHCS guidelines.
Nice To Haves
- Prior auditing experience.
Responsibilities
- Perform basic production and quality-control audits of routine internal claims and Medi-Cal providers, where limited judgment is required.
- Ensure quality meets in-house and/or external specifications and standards.
- Conduct comprehensive quality reviews of claims, enrollment, or customer service using a standard audit model.
- Identify policy and procedure revisions 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 and escalate 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.
- Review and interpret standards, procedural documentation, contracts, and legal verbiage independently.
- Provide guidance, coaching, and training to other employees within the job area.
- Perform other related duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
