Senior Quality Specialist

Position Summary Acts as an advocate and subject matter expert guiding the business by serving as a quality champion through measuring and monitoring the quality and effectiveness of work processes in claim processing and customer service that impact customer satisfaction, medical cost management, and operational efficiency. Consults cross-functionally with other departments to influence and promote change, to continually deliver quality service to both internal and external customers. Performs regular quality audits for service operations for multiple products and platforms to drive full and consistent compliance to all required standards. Additional Responsibilities Executes both routine and non-routine business support tasks for the Sr Quality Specialist area under limited supervision, referring deviations from standard practices to managers. Follows area protocols, standards, and policies to provide effective and timely support. Acts as a subject matter expert on Quality Specialist workflows, policies, systems requirements, and enhancements as well as daily operations and programs to consistently drive optimal results. Conducts standard quality reviews and audits to proactively measure and monitor team compliance with published policies, and procedures, to effectively meet customer and regulatory guidelines. Owns responsibility for supporting targeted quality audit projects, reporting overall results, and making recommendations regarding training needs, quality controls, and procedures to senior management. Takes direction to execute techniques, processes, and responsibilities. Required Qualifications 2+ years of health insurance work experience and/or Healthcare Insurance Quality Review 2+ years of experience working with diagnosis codes and medical terminology. Moderate to advanced knowledge of Excel (V-lookups, pivot tables, and/or formulas) Preferred Qualifications Working knowledge of problem solving and decision making skills College degree preferred Claims experience DG system experience Education High School Diploma or equivalent GED Anticipated Weekly Hours 40 Time Type Full time Pay Range $18.50 - $38.82 Benefits We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr 4062 Aetna Resources, LLC