Quality Assurance Specialist

Quality Assurance Specialist Qualifications Department: Care Management Services (CMS) Education Bachelor's degree in Healthcare Administration, Nursing, Business, Health Information Management, or related field preferred. Experience Minimum 2 to 3 years of healthcare operations experience. At least 1 year of Quality Assurance, Auditing, Compliance, or Performance Improvement experience. Experience auditing Enrollment, Eligibility Verification, Insurance Validation, and Care Management workflows. Experience conducting root cause analysis and calibration sessions. Technical Knowledge Knowledge of: Medicare and Medicaid guidelines Commercial insurance verification standards Healthcare documentation requirements Care Management workflows HIPAA and confidentiality standards Strong analytical and reporting skills. Core Competencies Attention to detail Critical thinking Data analysis Coaching and feedback delivery Process improvement Risk identification Stakeholder management Strong written communication Key Responsibilities Audit transactions, calls, cases, and documentation. Perform quality reviews against SOPs and client standards. Conduct calibration sessions with operations and training teams. Identify trends and performance risks. Provide coaching recommendations. Develop QA scorecards and audit tools. Track compliance and productivity metrics. Partner with Operations leadership to improve quality outcomes. Preferred Metrics Experience Quality scores Audit accuracy rates Compliance adherence Error reduction trends Corrective action effectiveness Process improvement initiatives Preferred Leadership-Level Competencies Required Healthcare BPO or Healthcare Operations experience Strong understanding of Enrollment & Eligibility functions Knowledge of Care Management Services workflows Advanced Excel and reporting skills Project management capabilities Experience creating and maintaining SOPs Preferred Lean Six Sigma Yellow Belt or Green Belt Certified Professional in Healthcare Quality (CPHQ) Certified Trainer designation Experience building quality and training programs from the ground up