Quality and Training Specialist / Auditor

Quality & Training Specialist

The Quality & Training Specialist is essential in promoting staff development, regulatory compliance, and ongoing performance excellence within the Grievance & Appeals (G&A) Department. This position is responsible for designing, facilitating, and evaluating training programs that equip team members with the knowledge and skills required to meet performance expectations and regulatory standards. This role includes conducting comprehensive training for new hires and providing ongoing refresher training based on identified needs through audits. Additionally, the Quality & Training Specialist will assist in auditing grievances, appeals, and State Fair Hearing cases as needed, supporting the Quality & Training Supervisor in enhancing overall quality and compliance with Department of Health Care Services (DHCS), National Committee on Quality Assurance (NCQA), and Center for Medicare & Medicaid Services (CMS) standards.

Responsibilities

Collaborates with the G&A Quality & Training Supervisor to develop, implement, and facilitate comprehensive onboarding and training programs for new hires within the G&A Department. Conducts ongoing refresher training sessions for existing staff based on identified needs from audits or performance evaluations. Collaborates with the G&A Quality & Training Supervisor to align training materials with departmental quality assurance goals and compliance standards. Creates and maintains training documentation, including manuals, guides, and resources to support staff development. Evaluates training effectiveness through assessments, feedback, and performance data; recommend and implement improvement as necessary. Provides mentorship and support to new hires during their onboarding process to ensure a smooth transition into their roles. Stays updated on changes in DHCS, NCQA, and CMS regulations to ensure training content remains accurate and compliant and incorporates relevant information into training sessions. Identifies and addresses skill or knowledge gaps through audits and quality reviews and develops targeted training interventions to address deficiencies and enhance performance and compliance. Performs additional duties as assigned in support of departmental objectives.

Secondary Duties and Responsibilities Conducts concurrent and retrospective audits of individual cases according to established audit criteria and provides feedback to associates as applicable. Performs routine and timely quality assurance audits of all types of cases, including grievances, appeals, and State Fair Hearings. Assesses cases to determine if DHCS and CMS mandated timeframes, NCQA specifications, and Partnership professional standards for member experience are met. Enters audit findings of individual cases in the audit tracking database and provides summary reports to the Quality & Training Supervisor. May participate in special projects or initiatives as directed.

Qualifications

Education and Experience

Bachelor's degree in Healthcare Administration, Business Administration, or related field preferred; 2 years of experience with grievance, appeal, and State Fair Hearing cases or equivalent combination of education and experience. Strong knowledge of Experience with Medi-Cal, DHCS, NCQA, or other regulatory healthcare environment preferred. Experience in developing and delivering training programs in a healthcare or regulatory environment preferred.

Special Skills, Licenses and Certifications

Experience in managed care business practices and the ability to access data information using computer systems. Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines. Strong organizational skills required. Effective telephone, computer, and data entry skills required. Proficient in Microsoft Office Suite

Performance Based Competencies

Excellent written and verbal communication skills with ability to read and interpret benefit contract specifications are required. Ability to present information clearly and effectively. Ability to understand and ensure compliance with established criteria and protocols used in managed care functions. Ability to formulate ideas and solutions into appropriate questions and assess / interpret the verbal responses. Self-driven and works independently.

Work Environment And Physical Demands

More than 70% of work time is spent in front of a computer monitor. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs.

All HealthPlan employees are expected to :

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan's policies and procedures, as they may from time to time be updated.

HIRING RANGE :

$85,173.51 - $106,466.89

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.