Quality and Training Specialist/Auditor

Overview
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. Selfdriven 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, $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.