Quality Specialist at BMC HealthNet Plan

3 weeks ago QA Middle Full-Time

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This role is responsible for validating employees outputs in various areas including; Claims, Customer Care and Enrollment to ensure quality, accuracy, and regulatory compliance.

Education Required:

  • Bachelor’s degree in Business Administration, Education, related field, or an equivalent combination of education, training and experience is required.
  • Required Experience:
  • A minimum of 1-3 years of Quality Control, Quality Assurance and Auditing.
  • 1-3 years exposure in various departments in a health insurance organization such as; customer service, and/or enrollment, claims and premium billing experience or equivalent experience is required.
  • Working knowledge of Managed Care Operations including basic understanding in Claims, Enrollment and Customer Service functions with application of Quality Improvement concepts, practices, and procedures is required.


  • Previous health insurance work experience.
  • Experience in working with Witness or other call monitoring software.
  • Previous call center quality assurance experience preferred.
Competencies, Skills, and Attributes:
  • Strong interpersonal communication and relational skills.
  • Must be able to work collaboratively and cooperatively as a team member.
  • Ability to synthesize and process complex information and deliver the information both verbally and in writing in a clear, concise and articulate manner.
  • Highly organized, detail oriented and self-directed with the ability to work independently and in team settings.
  • Demonstrated competency with MS Office and MS Windows, specifically in Microsoft Excel.
  • Excellent analytical, oral, verbal, and written communication skills and customer service skills.
  • Must be able to multi-task, prioritize projects and work well with deadlines.
  • Must be flexible and willing to perform all necessary and appropriate duties to ensure the attainment of departmental and organizational goals.
  • Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status


The Quality Specialist performs a critical function within Health Plan Operations. This role is responsible for validating employees outputs in various areas including; Claims, Customer Care and Enrollment to ensure quality, accuracy, and regulatory compliance. The Quality Specialist collaborates with business partners across Operations and external vendors to create and maintain quality policies and processes to assure program meets the agreed upon standards.

Key Functions/Responsibilities:

  • Evaluates department outputs for accuracy and compliance with processing guidelines and departmental standards in order to validate process and workflow effectiveness and efficiency.
  • Perform quality audits on Membership eligibility and enrollment entry for accuracy and timeliness in accordance with regulatory standards and regulatory agencies.
  • Prepares and maintains Quality policies and procedures.
  • Conducts research, compiles and analyzes performance reports to identify the root cause of problems and recommend process improvements.
  • Participates with stakeholders to develop potential preventive and/or corrective actions.
  • Monitor external vendor quality, investigate discrepancies, and report errors to the appropriate operation team.
  • Conduct accurate and timely quality reviews of claim adjudication activities including appropriate adjudication decisions, accuracy of claim payment in compliance with adjudication policies and procedures, job aids and guidelines.
  • Assist in the appeal process by providing supporting documentation and reference tools sited in the determinations and/or audit findings.
  • Tracks daily evaluation completion of assigned processing task/function and provides any noticeable performance trend data to appropriate management team or Business Owner.
  • Coaches and provides ongoing feedback to staff based on trends and Quality findings.
  • Conducts one-on-one coaching as determined by management for performance improvement.
  • Assists with calibration sessions in accordance with department standards, to help ensure consistency and validation of audit parameters, KPIs, and requirements.
  • Provides suggestions on new process documentation and materials to support quality initiatives and to improve overall performance and compliance across the Operations teams.
  • Provides feedback to department team leaders and managers.
  • Identifies and documents defects, inconsistences and potential risk in workflow process and documentation.
  • Maintains a comprehensive understanding of appropriate departmental policies and procedures and audit specification.

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