Claims QA Analyst ([phone removed]) - (Orange, CA)

The position is responsible for auditing claims activity performed in the claims department following regulatory and internal guidelines in conjunction with CalOptima policies and procedures. The QA Analyst oversees and implements quality improvement activities from trend reports and works closely with supervisors and trainers to identify training opportunities. This position has analytical, and/or administrative responsibilities specific to the department. Job duties: Conduct audit review of claims processed. Perform focused audits as needed. Audit of auto adjudication of claims (system process). Audit of programs and carve-outs performed in the claims department (i.e.member billing, reinsurance, etc). Responsible for auditing Medi-Cal and OneCare and involves specialized background or knowledge regarding claims processing rules, regulatory guidelines relevant to the assignment. Often work unaided, performs more complex research, and/or administrative responsibilities.