Operational Quality Services Specialist, Associate

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. 

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. 

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!  

Our Values: 

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short. 
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals. 

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail. 

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

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 

• Requires a college degree or equivalent experience
• 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.