Operational Quality Services Specialist, Associate

Blue Shield of California; California; Hybrid; USD 39,000 - 55,000; Full time

Benefits offered by this job

Hybrid work

Job summary

Blue Shield of California is seeking an Operational Quality Services Auditor to join the team that conducts audits, documents quality issues and performance measures, and ensures alignment with service level requirements.

The role reports to the Operational Quality Services Supervisor and focuses on production and quality control audits, identifying performance deficiencies, and creating management reporting for follow-up.

Qualifications

• Bachelor’s degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree required.
• Knowledge in health care compliance, legislative or legal services, healthcare, privacy, audit or investigative services preferred.
• Practical knowledge of production and quality control audits typically obtained through advanced education combined with experience preferred.
• Knowledge and experience with claims processing preferred.

Responsibilities

• Perform basic production and quality control audits for internal claims and external Medicare, HMO or PPO providers.
• Conduct comprehensive quality reviews of claims, enrollment, or customer service using a standard audit model.
• Identify revisions to policies and procedures to comply with regulatory changes and train internal staff or delegated providers.
• Draft communications to operations when necessary
• Report, maintain quality and corrective actions.
• Represent Blue Shield of California with internal/external entities when needed
• Review lower-level employee work and provide feedback
• Communicate audit issues promptly and propose solutions
• Participate in corrective and preventive action planning
• Interact with operations to influence outcomes
• Contribute to development of claims training, projects and task forces as assigned.

Skills

Quality audits

Claims processing

Auditing

Quality control

Education

Bachelor's degree or equivalent (HS diploma + 4 years experience)

Job description

Your Role

The 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.

Job Description

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.

Responsibilities

• 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 necessary
• Responsible for reporting, maintaining quality and corrective actions.
• May represent BSC with internal/external entities.
• May review lower-level employee work
• Communicate audit issues immediately, and provide potential solutions
• May 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.

Qualifications

• Bachelor’s degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree required
• Knowledge in health care compliance, legislative or legal services, healthcare, privacy, audit or investigative services preferred
• Practical knowledge of production and quality control audits typically obtained through advanced education combined with experience preferred
• Knowledge and experience with claims processing preferred

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.

About Us

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.

JOB INFO

Job Identification : 20261909

Job Category : Customer Services and Operations

Posting Date : 2026-10-01T18:00:27+00:00

Job Schedule : Full time

Locations :

Redding, CA, United States

Long Beach, CA, United States

El Dorado Hills, CA, United States

Lodi, CA, United States

Oakland, CA, United States

Rancho Cordova, CA, United States

San Diego, CA, United States

Woodland Hills, CA, United States

Pay Range for California : $28.33 to $39.66

Pay Range for Bay Area : $31.94 to $44.71

Note : Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.

Role can be filled by a candidate requiring sponsorship : No