Quality Assurance Auditor, Specialist

Your Role

The Provider Dispute Resolution (PDR) Quality Assurance team under Healthcare Business Operations completes a variety of quality audits on the PDR onshore and offshore teams to ensure that DMHC standards are met on a monthly basis. The Quality Assurance Auditor - Specialist will report to the Senior Manager of the Quality Assurance Audit Team. In this role you will conduct audits on the Commercial Coordinators of the PDR Team, document audit findings monthly and audit observations and trends, communicate quality issues and performance measures to supervisors immediately, provide coaching to PDR coordinator staff as needed, and conduct reviews of policies and procedures to ensure alignment with service level requirements. You will also be involved in the training of new PDR Coordinator staff as needed.

Your Work

In this role, you will:

• Be responsible for performing audits that are routine in nature where limited judgment is required.
• Focus on single area of expertise or line of business (Commercial); 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.
• Provide coaching and other feedback to coordinators in a timely manner and be considered a subject matter expert in audit principles and methodologies.
• Communicate monthly audit trends to leadership via email, reports, and virtual meetings.
• Manage timelines, assignments, and work plans and adhere to monthly audit volume agreements with the business unit.
• Work with the PDR business unit supervisors and leaders to maintain optimal relationships, attend monthly PDR leadership meetings as needed, and have excellent communication skills.
• Conducts comprehensive quality reviews to identify performance deficiencies; may use quality analysis tools to analyze trends, root causes and identify systemic corrective action opportunities.

Your Knowledge and Experience

• Requires a high school diploma or GED
• Requires at least 7 years of prior relevant experience
• Requires expertise in the Commercial and/or Medi-Cal line of business
• Requires knowledge of Microsoft Systems such as Power Point, Excel, and Word
• Requires previous experience working for a payor in claims or similar business unit
• Prior auditing and/or compliance/regulatory experience is preferred

Pay Range:

The pay range for this role is: $ 24.48 to $ 34.27 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.