Blue Shield of California is a nonprofit healthcare organization that aims to create a sustainable and affordable healthcare system. The Operational Quality Services Specialist, Associate will be responsible for performing audits on the Medi-Cal line of business, ensuring claims are processed accurately and in compliance with regulatory standards.

Responsibilities

• 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

Skills

• Requires a college degree or equivalent experience
• Requires relevant experience
• Minimum 1 or more years previous claims processing experience of all claim types
• Knowledge of DHCS guidelines
• Prior auditing experience preferred

Benefits

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

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