Quality Improvement Specialist

Operational Quality Services AuditorThe Operational Quality Services team conducts audits, documents quality issues and performance measures and conduct reviews of policies and procedures to ensure alignment with service level requirements. The Operational Quality Services Auditor will report to the Operational Quality Services Supervisor. In this role you will be responsible for performing production and quality control audits to measure performance. Assures adherence to established specifications and quality standards. Conducts comprehensive quality review to identify performance deficiencies. May use quality analysis tools to analyze trends, root causes and identify systemic corrective action opportunities. Creates management reporting for review and follow up. Other duties as assigned.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.ResponsibilitiesIn this role, you will:Responsible for performing basic production and quality control audits for internal claims and external Medicare, HMO or PPO providers.Conducts comprehensive quality reviews of claims, enrollment, or customer service using a standard audit model.Responsible for identifying revision of policies and procedures to comply with regulatory changes and for training internal staff or delegated providers.Draft communications to operations when necessaryResponsible for reporting, maintaining quality and corrective actions.May represent BSC with internal/external entities.May review lower-level employee workCommunicate audit issues immediately, and provide potential solutionsMay participate in corrective/preventative action planning.Interacts with operation representatives to influence outcomes.May participate in the development of claims training, projects and taskforces as assigned.QualificationsIn this role, you will need:Bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degreeKnowledge in health care compliance, legislative or legal services, healthcare, privacy, audit or investigative services preferredPractical knowledge of production and quality control audits typically obtained through advanced education combined with experienceKnowledge and experience with claims processing preferredHybridThis role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.About UsAs 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.Our Workplace ModelWe believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility: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.The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.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. Blue Shield Of California