Quality Assurance Auditor, Specialist

Blue Shield of California • Rancho Cordova, CA

3d • Hybrid

About The Position

The Quality Review team completes audits of front-line staff to ensure alignment with department processes and regulatory compliance. Quality Assurance Auditors also provide coaching and work closely with business leaders to drive optimal results. The Quality Assurance Auditor, Specialist will report to the Quality Review Senior Manager. In this role you will develop performance metrics audit tools, evaluate performance, and provide coaching to ensure that staff have the skills and knowledge required to be successful in Appeals & Grievance (AGD). 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

• Requires a high school diploma or GED
• Requires at least 7 years of prior relevant experience
• Attention to details and the ability to communicate effectively
• Knowledge of Health Plan operations, lines of business, general healthcare industry standards
• Strong organizational skills to conduct audits and reporting timely

Nice To Haves

• Auditing experience preferred
• Experience in AGD preferred
• Hands-on experience using MS Office applications including Excel, Word, Outlook, PowerPoint preferred

Responsibilities

• Performing audits that are routine in nature where limited judgment is required
• Focus on single area of expertise or line of business (Claims, Inquiry, Enrollment); objectively review and interpret standards, procedural documentation and contract and legal verbiage
• Identify and document audit observations and findings
• Notify Supervisor when communications with operations are necessary; coordinate appropriate messaging
• Identify and resolve routine problems independently; escalate issues with Supervisor as appropriate
• Contributes to meeting and improving compliance performance
• Review audit data to identify care gaps, compliance risks, and trends
• Provide developmental coaching and support to all staff to improve the skills and competencies required to successfully perform work

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED