Operational Quality Services Specialist, Associate

Your Role

The Medi-Cal Operations team is responsible for ensuring claims are processed accurately and in a timely manner. The Operational Quality Services Specialist, Associate will report to the Medi-Cal Operations Senior Manager of direct manager. In this role you will be responsible for performing audits that are routine in nature for the Medi-Cal line of business for all claim types.

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.

Your Knowledge and Experience

• Bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree
• Requires relevant experience
• Prior auditing experience preferred
• Minimum 1 or more years previous claims processing experience of all claim types
• Knowledge of DHCS guidelines

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

Your Work

In this role, you will:

• Be responsible for performing basic production and quality control audits for internal claims and Medi-Cal providers that are routine in nature where limited judgement is required
• Assure quality to in-house and/or external specifications and standards
• Conduct comprehensive quality reviews of claims, enrollment, or customer service using a standard audit model
• Be responsible for identifying revision of policies and procedures to comply with regulatory changes and for training internal staff or delegated providers
• Initiate corrective measures and track timely completion
• Identify and resolve routine problems independently; escalate issues with Supervisor as appropriate
• Identify root cause of errors and perform impact analysis as well as the ability to effectively communicate mitigation steps to appropriate parties
• Maintain current and comprehensive knowledge of all applicable claims regulatory requirements, including AB 1455 and DHCS regulations
• Ability to independently review and interpret standards, procedural documentation, contracts and legal verbiage
• Responsible for providing guidance, coaching and training to other employees within job area
• Other related duties as assigned

Your Work

In this role, you will:

• Be responsible for performing basic production and quality control audits for internal claims and Medi-Cal providers that are routine in nature where limited judgement is required
• Assure quality to in-house and/or external specifications and standards
• Conduct comprehensive quality reviews of claims, enrollment, or customer service using a standard audit model
• Be responsible for identifying revision of policies and procedures to comply with regulatory changes and for training internal staff or delegated providers
• Initiate corrective measures and track timely completion
• Identify and resolve routine problems independently; escalate issues with Supervisor as appropriate
• Identify root cause of errors and perform impact analysis as well as the ability to effectively communicate mitigation steps to appropriate parties
• Maintain current and comprehensive knowledge of all applicable claims regulatory requirements, including AB 1455 and DHCS regulations
• Ability to independently review and interpret standards, procedural documentation, contracts and legal verbiage
• Responsible for providing guidance, coaching and training to other employees within job area
• Other related duties as assigned