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 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 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.