Quality Assurance Compliance Analyst - Remote CA

Gainwell Technologies LLC•West Sacramento, CA

9d•$53,900 - $77,000•Remote

About The Position

As a Quality Assurance Compliance Analyst at Gainwell, you will support quality and compliance activities across healthcare operations for the Medi-Cal account. You will review claims and operational processes, analyze data to identify quality trends and potential issues, and help ensure work is completed accurately and in accordance with established policies, regulatory requirements, and organizational standards. You will partner with claims, clinical, compliance, and operational teams to identify opportunities for improvement and strengthen overall quality and performance.

Requirements

High school diploma or GED required; bachelor’s degree or equivalent professional experience preferred.
Three or more years of experience in quality assurance, compliance, auditing, healthcare operations, claims, or a related field.
Experience with healthcare claims adjudication, claims validation, denials, appeals, billing, or related healthcare operational processes.
Knowledge of common claims quality issues, coding errors, and healthcare quality or compliance requirements.
Familiarity with Medicaid or Medi-Cal operations and regulatory requirements, including DHCS or other applicable state regulatory or accreditation requirements, preferred.
Experience analyzing data, identifying trends, conducting root-cause analysis, and supporting process improvement initiatives.
Experience maintaining quality documentation, audit findings, and audit trails.
Knowledge of systems such as EDMS, NICE CXone, or MMIS is a plus.
Strong analytical, problem-solving, organizational, and communication skills with excellent attention to detail.

Nice To Haves

Bachelor’s degree or equivalent professional experience
Familiarity with Medicaid or Medi-Cal operations and regulatory requirements, including DHCS or other applicable state regulatory or accreditation requirements
Knowledge of systems such as EDMS, NICE CXone, or MMIS

Responsibilities

Conduct quality reviews and audits of healthcare claims and operational processes to evaluate accuracy, completeness, and compliance with established policies, procedures, and regulatory requirements.
Analyze claims data to identify trends, anomalies, coding errors, quality issues, and opportunities for improvement.
Review claims, denials, appeals, provider enrollment, and related operational activities to validate data accuracy and identify potential compliance or quality concerns.
Document audit findings, maintain appropriate audit trails, analyze quality metrics, and communicate findings to operational and non-technical stakeholders.
Participate in root-cause analysis and recommend corrective actions and process improvements based on audit findings and identified trends.
Support compliance and regulatory reporting, internal and external audits, and quality improvement initiatives in collaboration with claims, clinical, compliance, and operational teams.