Qureos Mentor

Blue Shield of California

<div>Your Role 
The Medi-Cal Operations team is responsible for ensuring claims are processed accurately and timely. The Claims Processor, Specialist will report to the Medi-Cal Operations Supervisor. In this role you will be responsible for interfacing with other departments and vendors involved in the Claims process and will also serve as the primary point of contact for priority claim cases. 
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow &ndash; personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.</div>
 <div>Your Work 
In this role, you will:
<ul><li>Handle most complex activities including backup for all areas of claims processing
</li><li>Actively participate in projects
</li><li>Handle escalated issues independently
</li><li>Mentor experienced team members
</li><li>Assist with training when needed
</li><li>Collaborate with peers, staff in other department's vendors, and Management to improve processes and department work quality.
</li><li>Must be able to work in a fast-paced environment with minimal supervision
</li><li>Read and interpret documents such as provider contracts procedure manuals, various reports, division of financial responsibility matrix</li></ul></div>
 <div>Your Knowledge and Experience 
<ul><li>Requires a high school diploma or GED
</li><li>Requires at least 7 years of experience
</li><li>Minimum of 3 years of experience in claims processing and/or auditing experience in a manage care setting required
</li><li>Experience examining multiple claim types in the Medi-Cal/Medicare environment preferred
</li><li>Knowledge of medical claims regulatory guidelines such as AB1455 and Medicare preferred
</li><li>Proficiency in Microsoft Office programs such as Excel, Word and Outlook required 
</li></ul>Hybrid Virtual Work
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.</div>
 <div>ABOUT THE TEAM 
About Blue Shield of California
As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities &ndash; join us!
Our Values:
<ul><li>Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
</li><li>Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
</li><li>Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
</li></ul><div>Our Workplace Model
We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:
<ul><li>For most teams, this means coming into the office two days per week.
</li><li>Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
</li><li>For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
</li></ul>The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.
</div>Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day. 
Equal Employment Opportunity:
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.</div>

Claims Processor, Specialist

<div>
 
 Job Description
 
 
 
 
 Your Role
 
 
 
 The Clinical Quality team oversees and is responsible of HEDIS medical record review, pursuit, and overall HEDIS submission. The Clinical Quality Coordinator, Entry will report to the Supervisor of the HEDIS Outreach Team. In this role you will be responsible for conducting provider outreach during the HEDIS season for medical record pursuit and retrieval. Also, participation in Quality initiatives involving member outreach for care gap closure. Responsible for maintaining high productivity and standard work.
 
 
 Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow &ndash; personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
 
 
 
 Responsibilities
 
 
 
 
 Your Work
 
 
 
 
 In this role, you will:
 
 
 
 <ul>
 <li>
 Initiate outbound calls to members and providers to collect information and provide care coordination assistance in obtaining services (schedule appointments, provider appointment reminders, coordinate transportation, etc.)
 </li>
 <li>
 Educate members on missing care gaps and provide encouragement to obtain missing service.
 </li>
 <li>
 Request medical records from PCP/Specialists by fax, remote EMR access or scheduled site visits as needed
 </li>
 <li>
 Manage and maintain HEDIS files and medical records
 </li>
 <li>
 Provide administrative support, including generating correspondence, organize mass mailings, coordinator schedules and training
 </li>
 <li>
 Continued development of understanding of HEDIS hybrid measures and medical record requirements for HEDIS compliance
 </li>
 <li>
 Research member claims and encounters to identify accurate pursuit information for medical record retrieval
 </li>
 <li>
 Review medical records and identify elements for compliance
 </li>
 <li>
 Create and maintain detailed logs of member and provider interactions
 </li>
 <li>
 Ability to de-escalate situations
 </li>
 <li>
 Assist in onboarding contingent workforce for HEDIS and outreach projects
 </li>
 <li>
 EMR and vendor portal medical record retrieval
 </li>
 <li>
 Developing understanding of HEDIS pursuit processes relative to pursuit systems and tracking processes
 </li>
 <li>
 Developing understanding of outreach and pursuit project intake procedures, schedules, and reporting requirements
 </li>
 <li>
 Ability to work independently in a fast-paced environment with minimal errors
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 
 Your Knowledge and Experience
 
 
 
 <ul>
 <li>
 Requires a high school diploma or equivalent
 </li>
 <li>
 Requires limited knowledge of systems and procedures
 </li>
 <li>
 Typically, has limited or no prior experience
 </li>
 <li>
 Communication and interpersonal skills
 </li>
 <li>
 Must be organized with the ability to keep accurate notes and records
 </li>
 <li>
 Customer service experience is preferred
 </li>
 <li>
 HEDIS knowledge strongly preferred
 </li>
 <li>
 Critical thinking skills
 </li>
 <li>
 Knowledge of computer applications including Microsoft Word, PowerPoint and Excel. Internet knowledge with the ability to complete searches
 
 
 </li>
 </ul>
 
 Hybrid Virtual Work
 
 
 
 This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.
 
 
 
 About The Team
 
 
 
 
 About Blue Shield of California
 
 
 
 As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
 
 
 At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
 
 
 To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
 
 
 Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities &ndash; join us!
 
 
 
 Our Values:
 
 
 
 <ul>
 <li>
 Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
 </li>
 <li>
 Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
 </li>
 <li>
 Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
 
 
 </li>
 </ul>
 
 Our Workplace Model
 
 
 
 We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:
 
 
 <ul>
 <li>
 For most teams, this means coming into the office two days per week.
 </li>
 <li>
 Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
 </li>
 <li>
 For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
 
 
 </li>
 </ul>
 The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.
 
 
 
 Physical Requirements:
 
 
 
 Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
 
 
 Please click here for further physical requirement detail.
 
 
 
 Equal Employment Opportunity:
 
 
 
 External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
</div>

Clinical Quality Coordinator, Entry

<div>Your Role 
 
The Clinical Quality team oversees and is responsible of HEDIS medical record review, pursuit, and overall HEDIS submission. The Clinical Quality Coordinator, Entry will report to the Supervisor of the HEDIS Outreach Team. In this role you will be responsible for conducting provider outreach during the HEDIS season for medical record pursuit and retrieval. Also, participation in Quality initiatives involving member outreach for care gap closure. Responsible for maintaining high productivity and standard work. 
 
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow &ndash; personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.</div>
 <div>Your Work
In this role, you will:
<ul><li>Initiate outbound calls to members and providers to collect information and provide care coordination assistance in obtaining services (schedule appointments, provider appointment reminders, coordinate transportation, etc.)
</li><li>Educate members on missing care gaps and provide encouragement to obtain missing service.
</li><li>Request medical records from PCP/Specialists by fax, remote EMR access or scheduled site visits as needed
</li><li>Manage and maintain HEDIS files and medical records
</li><li>Provide administrative support, including generating correspondence, organize mass mailings, coordinator schedules and training
</li><li>Continued development of understanding of HEDIS hybrid measures and medical record requirements for HEDIS compliance
</li><li>Research member claims and encounters to identify accurate pursuit information for medical record retrieval
</li><li>Review medical records and identify elements for compliance
</li><li>Create and maintain detailed logs of member and provider interactions
</li><li>Ability to de-escalate situations
</li><li>Assist in onboarding contingent workforce for HEDIS and outreach projects
</li><li>EMR and vendor portal medical record retrieval
</li><li>Developing understanding of HEDIS pursuit processes relative to pursuit systems and tracking processes
</li><li>Developing understanding of outreach and pursuit project intake procedures, schedules, and reporting requirements
</li><li>Ability to work independently in a fast-paced environment with minimal errors</li></ul></div>
 <div>Your Knowledge and Experience
<ul><li>Requires a high school diploma or equivalent
</li><li>Requires limited knowledge of systems and procedures
</li><li>Typically, has limited or no prior experience
</li><li>Communication and interpersonal skills
</li><li>Must be organized with the ability to keep accurate notes and records
</li><li>Customer service experience is preferred
</li><li>HEDIS knowledge strongly preferred
</li><li>Critical thinking skills
</li>Knowledge of computer applications including Microsoft Word, PowerPoint and Excel. Internet knowledge with the ability to complete searches 
<li>
</li></ul>Hybrid Virtual Work
 
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.</div>
 <div>ABOUT THE TEAM 
About Blue Shield of California
As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities &ndash; join us!
Our Values:
<ul><li>Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
</li><li>Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
</li><li>Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
</li></ul><div>Our Workplace Model
We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:
<ul><li>For most teams, this means coming into the office two days per week.
</li><li>Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
</li><li>For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
</li></ul>The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.
</div>Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day. 
Equal Employment Opportunity:
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.</div>

Join Blue Shield of California and explore 3   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Blue Shield of California

About Company

Claims Processor, Specialist

Clinical Quality Coordinator, Entry

Clinical Quality Coordinator, Entry