Quality Assurance Auditor, Specialist

Quality Assurance Auditor, Specialist

The Internal Audit team is responsible for performing compliance and contractual audits such as Licensee Desk Level Audit, Local Operations Scorecard, and Federal Employee Program. The Quality Assurance Auditor, Specialist will report to the Internal Audit Senior Manager. In this role you will be ensuring adherence to established specifications, quality standards, contractual agreements, and Blue Cross Blue Shield Association guidelines and conduct comprehensive quality reviews to identify performance deficiencies.

Responsibilities

In this role, you will:

• Be responsible for performing transactional quality review audits with minimal supervision
• Audit multiple areas, including Claims, Customer Service, Enrollments, etc.
• Objectively review and interpret standards, procedural documentation and contract and legal verbiage
• Identify and accurately document observations and findings
• Draft and communicate audit findings to Operations
• Research and respond to audit rebuttals
• Participate in corrective/preventive action planning and implementation related to audits
• Research issues and share the findings of that work with varying groups effectively (executives, managers, line staff, etc.)
• Identify and resolve problems independently; consult on complex issues

Qualifications

Your Knowledge and Experience:

• Requires a high school diploma or GED
• Requires at least 7 years of prior relevant experience
• Knowledge and experience in one or more Blue Shield Operational areas, such as: Claims processing, Customer Service, Enrollment
• Audit and claims experience strongly desired
• Strong organizational skills, attention to detail, reading comprehension and analytical skills
• Strong written and verbal communication skills

Hybrid

This 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 Us

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.

Our Workplace Model

We 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.