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.

▪ 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.

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:

$85,173.51 - $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.